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Property of the 

Lancaster City and County 
Medical Society 



No 



I Received, 

|Title,..^S^^r^. 

! Binding ....j 

I 

i Residence, 

I Cost, 



THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 

ISAAC HAYS, M.D., 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OF THE 
AMERICAN MEDICAL ASSOCIATION J OF THE AMERICAN PHILOSOPHICAL SOCIETY J OF THE 
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA ; ASSOCIATE FELLOW 
OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES, 

&c. &c. &c. 



NEW SERIES. 
VOL. XXXV. 




PHILADELPHIA: 

BLANCHARD & LEA. 



1858. 



69461 



Entered according to the Act of Congress, in the year 1858, by 
BLANCHARD AND LEA, 

in the Office of the Clerk of the District Court of the United States in and for the 
Eastern District of the State of Pennsylvania. 




PHILADELPHIA : 
COLLINS, PRINTER. 



TO READERS AND CORRESPONDENTS. 



The communication of Dr. J. B. Porter is in type, and shall appear in our 
next No., as shall also the papers of Drs. Casselberry and Halsey. 

A number of communications are on hand which shall receive early attention. 

In the review of the " Report of Sickness and Mortality in the U. S. Army." 
which appeared in the number of this Journal for July last, an apparent dis- 
crepancy in the statistics of cholera was noted {vide p. 138 of July No.). This, 
we learn from an authentic source, is to be explained by the fact that all the 
quarterly abstracts throughout that work are for quarters ending on the 31st 
March, 30th June, 30th September, and 31st December ; the year being from 
January to January. This course was adopted for the purpose of showing the 
influence of the seasons in each year. In the consolidated abstract, which em- 
braces the yearly record of all the diseases occurring in the army {vide pages 
488 to 493 of Report), the official annual reports of the Surgeon-General were 
followed, which are required, by law, to be made for the fiscal year, beginning 
on July 1st, and ending on June 30th following. 

The following works have been received: — 

Medical and Statistical Returns of the Baltic and Black Sea Fleets during 
the years 1854 and 1855. Ordered by the House of Commons, February, 1857. 
(From the Admiralty.) 

Disorders of the Blood. By Julius Vogel, M. D., Prof, of Clinical Medicine 
in the University of Giessen. Translated and edited by Chunder Coomar Dey, 
Graduate of the Medical College of Bengal. Calcutta, 1856. (From the 
Translator.) 

Ophthalmic Hospital Reports, and Journal of the Royal Ophthalmic Hospital. 
Edited by J. F. Streatfeild. October, 1857. (From the Editor.) 

The Medical Profession in Great Britain and Ireland, with an Account of 
the Medical Organization of France, Italy, Germany, and America. By Edwin 
Lee.M.D. Parts I. and II. London, 1857. (From the Author.) 

Human Histology in its Relations to Descriptive Anatomy, Physiology, and 
Pathology. With 434 illustrations on wood. By E. R. Peaslee, A. M., M. D., 
&c. &c. Philadelphia: Blanchard & Lea, 1857. (From the -Publishers.) 

Lectures on the Diseases of Women. By Charles West, M. D., &c. Part I. 
Diseases of the Uterus. Philadelphia: Blanchard & Lea, 1857. (From the 
Publishers.) 

Medical Lexicon. A Dictionary of Medical Science ; containing a Concise 
Explanation of the Various Subjects and Terms of Anatomy, Physiology, Pa- 
thology, Hygiene, &c. &c. &c, with French and other Synonymes. By Robley 
Dunglison, M. D., &c. &c. &c. Revised and very greatly enlarged. Philadel- 
phia: Blanchard & Lea, 1857. (From the Publishers.) 

The Principles and Practice of Obstetrics ; Including the Treatment of Chronic 
Inflammation of the Uterus, considered as a Frequent Cause of Abortion. By 
Henry Miller, M. D., Prof, of Obstetric Medicine in Med. Depart. Univ. of 
Louisville. With illustrations on wood. Philadelphia : Blanchard & Lea, 1858. 
(From the Publishers.) 

Materia Medica and Therapeutics ; with Ample Illustrations of Practice in 
all the Departments of Medical Science, with very copious Notes of Toxicology, 
&c. A new edition, revised and enlarged. By Thos. D. Mitchell, M. D., 
Professor of Materia Medica in Jefferson Medical College. Philadelphia: J. B. 
Lippincott & Co., 1857. (From the Publishers.) 

A Collection of Remarkable Cases in Surgery. By Paul F. Eve, M. D., 
Professor of Surgery in the University of Nashville. Philadelphia: J. B. Lip- 
pincott & Co., 1857. (From the Publishers.) 



4 



TO READERS AND CORRESPONDENTS. 



A Practical Treatise on the Diseases of Children. By J. Forsyth Meigs, 
M. D., &o. Third edition, carefully revised. Philadelphia: Lindsay & Blakis- 
ton, 1858. (From the Publishers.) 

Report of an Operation for Removing a Foreign Body from Beneath the 
Heart. By E. S. Cooper, M. D. Published by the San Francisco Medico-Chi- 
rurgical Association. San Francisco, 1857. 

Researches on Epilepsy : its Artificial Production in Animals, and its Etio- 
logy, Nature, and Treatment in Man. By B. E. Brown-Sequard, M. D., &c. 
Boston, 1857. (From the Author.) 

Puerperal Fever: its Causes and Modes of Propagation. By Jos. M. Smith, 
M. D., &c. Read before the New York Academy of Medicine, 4th April, 1857. 
New York, 1857. (From the Author.) 

Reports of Cases in the Surgical Practice of the Brooklyn City Hospital. 
By Robt. 0. Butler, M. D. (From Dr. Jos. C. Hutchinson.) 

Report on Infant Mortality in Lnrge Cities: the Sources of its Increase and 
Means of its Diminution. By D. M. Reese, M. D. 

Transactions of the American Medical Association. Instituted 1847. Vol. 
X. Philadelphia, 1857. 

The Transactions of the New Hampshire Medical Society (Sixty-seventh 
Anniversary), held at Concord, June 2 and 3, 1857. Concord, 1857. 

Transactions of the Medical Society of South Central New York, at the Tenth 
and Eleventh Annual Meetings, held at Binghampton, June 3, 1856, and at 
Owego, June 2, 1857. Binghampton, 1857. (From Dr. J. G. Orton.) 

Transactions of the Second Session of the Medical Society of the State of 
California, convened at Sacramento, Feb. 11, 1857. Sacramento, 1857. 

Prize Essay. Rational Therapeutics ; or, the Comparative Value of Different 
Curative Means, and the Principles of their Application. " Natura duce." 
By Worthington Hooker, M. D. Boston, 1857. (From the Author.) 

An Essay on the Preservation of Health. By Goodvvyn Nixon, M. D., 
Lowndes, Ala. Hayneville, Ala., 1857. 

An Address on the Life and Character of Robert M. Porter, M. D., late Pro- 
fessor of Anatomy in the University of Nashville. By J. Berrien Lindsley, 
M. D., Chancellor of the University. Nashville, Tenn., 1856. 

First Annual Report of the Superintendent of Health of the City of Provi- 
dence; ending July 1, 1857. Providence, 1857. 

Fourth Report to the General Assembly of Rhode Island, relating to the 
Registry and Returns of Births, Marriages, and Deaths in the State, for the 
year ending Dec. 31, 1856. Prepared under the direction of John R. Bartlett, 
Secretary of State, Providence, 1857. 

Experimental Researches Relative to the Nutritive Value and Physiological 
Effects of Albumen, Starch, and Gum, when Singly and Exclusively Used as 
Food. Being one of the Prize Essays of the American Medical Association 
for 1857. By Wm. A. Hammond, M."D., Assistant Surgeon U. S. A. Philadel- 
phia, 1857. 

Urethro-Vaginal and Vesico- Vaginal Fistules." By N. Bozeman, M. D., of 
Montgomery, Ala. Montgomery, 1857. (From the Author.) 

Annual Report to the Legislature of South Carolina Relating to the Regis- 
tration of Births, Deaths, and Marriages, for the year ending Dec. 31, 1856. 
Columbia, S. C, 1857. 

A Public Lecture on Medical Ethics, and the Mutual Relations of Patient 
and Physician. Delivered by appointment of the Memphis Medical Society. 
By A. P. Merrill, M. D. Memphis, 1857. (From the Author.) 

Introductory Lecture delivered by D. Warren Brickell, M. D., Professor of 
Obstetrics in New Orleans School of Medicine, Nov. 3, 1857. New Orleans, 
1857. 

Pneumonia; its Pathology and Treatment. By E. Read, M. D., of Terre 
Haute, Ind. Nashville, 1857. 

A Case of Fibrous Tumour of the Uterus, Accompanied with Excessive He- 
morrhage, Successfully Treated by Excision. By B. F. Baker, M. D. 

The Rights of Authors. By M. Paine, M. D. 



TO READERS AND CORRESPONDENTS. 



5 



The following Journals have been received in exchange: — 

Le Moniteur des Hopitaux Revue Medico-Chirurgicale de Paris. Redacteur 
en Chef M. H. De-Castelneau. September, October, November, 1857. 

Gazette Medicale de Paris. Nos. 34, 35, 36, 38, 39, 1857. 

Revue de Therapeutique Medico-Chirurgicale. Par A. Martin Lauzer, M. D. 
Sept., 1857. 

Journal de Medecine de Bordeaux. Redacteur en Chef, M. Costes. March, 
April, July, August, September, October, 1857. 

Eco Cientifico de Venezuela, Nicholas Milanohigo, Editor. April, May, 
June, July, August, September, October, 1857. 

La Espagiia Medica. Official de la Academia Quirurgica Cesaraugustana. 
Nos. 31, 36, 68, 69, 71. 

The Medical Times and Gazette. October, November, December, 1857. 

Edinburgh Medical Journal. September, October, December, 1857. 

British Medical Journal. Edited by Andrew Winter, M. D. September, 
October, November, 1857. 

The Dublin Hospital Gazette. August, October, November, 1857. 

The British and Foreign Medico-Chirurgical Review. October, 1857. 

The Journal of Psychological Medicine and Mental Pathology. Edited by 
Forbes Winslow, M. D., D. C. L. October, 1857. 

Guy's Hospital Reports. Edited by Sam'l Wilks, M. D , and Alfred Poland. 
Third Series, Vol. III. 

The Glasgow Medical Journal. October, 1857. 

The Sanitary Review and Journal of Public Health. Edited by Benjamin 
W. Richardson, M. D. October, 1857. 

Dublin Medical Press. Nov. 4, 1857. [This is the only No. of this valued 
Journal we have received for several months.] 

Archives of Medicine. Edited by Lionel S. Beale, M. B., F. R. S. No. 1. 

The Medical Chronicle. Edited by Wm. Wright, M. D., and D. C. McCal- 
lum, M. D. October, November, December, 1857. 

The Virginia Medical Journal. Edited by Drs. McCaw and Otis. October, 
November, December, 1857. 

Southern Medical and Surgical Journal. Edited by Henry F. Campbell, 
M. D. and Robert Camfbell, M. D. October, November, December, 1857. 

The American Journal of Insanity. Edited by the Medical Officers of the 
New York State Lunatic Asylum. October, 1857. 

The New Orleans Medical and Surgical Journal. Edited by Bennet Dow- 
ler, M. D. November, 1857. 

Charleston Medical Journal and Review. Edited by C. Happoldt, M. D. 
November, 1857. 

The North American Medico-Chirurgical Review. Edited by S. D. Gross, 
M.D., and T. G. Richardson, M. D. November, 1857. 

The New Orleans Medical News and Hospital Gazette. Edited by D. W. 
Brickell, M. D., and E. D. Fenner, M. D. November, December, 1857. 

The New York Journal of Medicine. Edited by Stephen Smith, M. D. 
November, 1857. 

Buffalo Medical Journal. Edited by Sandford B. Hunt, M.D., and Austin 
Flint, Jr., M. D. November, December, 1857. 

Nashville Journal of Medicine and Surgery. Edited by W. K. Bowling, 
M. D., assisted by PaulF. Eve, M. D. September, November, December, 1857. 

'The American Journal of Dental Science. Edited by Chapin A. Harris, 
M. D., D. D. S., and A. Snowden Piggot, M. D. October, 1857. 

The American Medical Gazette. Edited by D. Meredith Reese, M. D. Octo- 
ber, December, 1857. 

The Western Lancet. Edited by George C. Blackman, M. D. September, 
October, November, 1857. 

The Cincinnati Medical Observer. Edited by Drs. G. Mendenhall, J. A. 
Murphy, and E. A; Stevens. October, November, December, 1857. 

The Medical and Surgical Reporter. Edited by S. W. Butler, M. D. Octo- 
ber, November, Dece'mber, 1857. 



6 



TO READERS AND CORRESPONDENTS. 



The New Hampshire Journal of Medicine. Edited by Geo. H. Hubbard, 
M. D. October, November, December, 1857. 

The Southern Journal of the Medical and Physical Sciences. Edited by R. 
0. Currey, M. D. September, October, November, 1857. 

The Peninsular Journal of Medicine. Edited by Drs. Pitcher, Palmer, 
Brodie, and Christian. October, November, December, 1857. 

The St. Louis Medical and Surgical Journal. Edited by M. L. Linton, 
M. D., and Wm. M. McPheeters, M. D. September, November, 1857. 

The Medical Independent. Edited by M. Gunn, M. D., and L. G. Robinson, 
M. D. October, November, 1857. 

Atlanta Medical and Surgical Journal. Edited by Jos. P. Logan, M. D. ; and 
W. F. Westmorland, M. D. October, November, December, 1857. 

The North Western Medical and Surgical Journal. Edited by N. S. Davis, 
M. D. October, November, 1857. 

American Journal of Pharmacy. Edited by Wm. Procter, Jr. November, 
1857. 

The American Journal of Science and the Arts. Edited by Professors B. 
Silliman, B. Sillim an, Jr., and James D. Dana. November, 1857. 

The Ohio Medical and Surgical Journal. Edited by John Dawson, M. D. 
November, 1857. 

The American Druggists' Circular and Chemical Gazette. October, Novem- 
ber, December, 1857. 

The American Medical Monthly. Edited by E. H. Parker, M. D., and J. 
H. Douglas, M. D. December, 1857. 

Memphis Medical Recorder. Edited by Daniel F. Wright, M. D. July, 
September, November, 1857. 



Communications intended for publication, and Books for Review, should be sent, free 
of expense, directed to Isaac Hays, M. D., Editor of the American Journal of the Me- 
dical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed as 
above, and (carriage paid) under cover, to John Miller, Henrietta Street, Covent Gar- 
den, London; or M. Hector Bossange, Lib. quai Voltaire, No. 11, Paris, will reach us 
safely and without delay. We particularly request the attention of our foreign corre- 
spondents to the above, as we are often subjected to unnecessary expense for postage 
and carriage. 

Private communications to the Editor, may be addressed to his residence, 1525 
Locust St. 

All remittances of money, and letters on the business of the Journal, should be 
addressed exclusively to the publishers, Messrs. Blanchard & Lea. 

|g*gf The advertisement-sheet belongs to the business department of the Journal, 
and all communications for it should be made to the publishers. 

To secure insertion, all advertisements should be received by the 20th of the pre- 
vious month. 



CONTENTS 

OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 
NO. LXIX. NEW SERIES. 
JANUARY, 1858. 



ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

I. Observations on the Causes, Effects, and Treatment of Perforation of the 
Membrana Tympani. By Edward II. Clarke, M. D., Professor of Ma- 
teria Medica in Massachusetts Medical College. ----- 13 

II. Clinical Report on Pulmonary Tuberculosis ; giving an abridged ac- 
count of Twenty-four Cases of Arrested Tuberculosis, with Remarks on 
the Management of the Disease. By Austin Flint, M. D., Professor of 
Clinical Medicine and Medical Pathology in the University of Buffalo, 



N.Y. o 

III. The Vital Statistics of War, as shown by the Official Returns of the 
British Army During the War with Russia, and by those of the United 
States Army During the War with Mexico. By Assistant Surgeon 
Richard II. Coolidge, U. S. Army. 8G 

IV. Experiments with Bibron's Antidote to the Poison of the Rattlesnake. 

By William A. Hammond, M. D., Assist. Surg. U. S. Army. - - 94 

V. National Hotel Endemic. Autopsy ; Remarks. By Jas. J. Waring, 
M. D., Professor of Physiology in the National Medical College, Wash- 
ington, D. C. - - - - 97 

VI. Adhesive Plaster the best Counter-extending Means in Fractures of 
the Thigh. By D. Gilbert, M. D., Professor of Midwifery in the Medical 
Department of Pennsylvania College. 105 

VII. Case of Osteoid Growth connected with the Capsular Ligament of 
the Right Hip-Joint. By A. F. Sawyer, M. D., one of the Surgeons of 
the " Hospital of the Sisters of Mercy," San Francisco, Gal. (With three 
wood-cuts.) 109 

VIII. Cupping the Interior of the Uterus. By Horatio R. Storer, M. D. 
(Read before the Boston Society for Med. Observation, Oct. 19, 1857.) 117 

IX. Rupture of the Trachea, from a fall. Communicated by John L. 
Atlee, Jr., M. D., of Lancaster, Pa. 120 

X. Case of Fallopian Pregnancy resulting in Rupture of the Cyst and 
terminating in Death. Reported by Robert P. Harris, M. D., Philadel- 
phia. [Read before the Philadelphia Pathological Soc, Nov. 25, 1857.] 123 



8 



CONTENTS. 



ART. PAGE 

XI. A new Uterine Elevator. By J. Marion Sims, M. D., Surgeon to the 
Woman's Hospital, New York. (With a wood-cut.) - 132 

XII. Exsection of the Trunk of the Second Branch of the Fifth Pair of 
Nerves, beyond the Ganglion of Meckel, for Severe Neuralgia of the 
Face : with Three Cases. By J. M. Carnochan, Professor of Surgery in 
the New York Medical College, Surgeon-in-chief to the State Hospital 
(New York), &c. 134 

XIII. A Singular Case of Catalepsy successfully treated with the Nitrate 

of Silver. By Wm. K. King, M. D., of Louisburg, N. C. - - - 143 



REVIEWS. 

XIV. Elements of Pathological Anatomy. By Samuel D. Gross, M. D., 
Professor of Surgery in Jefferson Medical College, &c. Third edition, 
modified and thoroughly revised. Illustrated by 342 engravings an wood. 
Blanchard & Lea: Philad. 1857 8vo. pp. 771. 145 

XV. Human Histology, in its Relations to Descriptive Anatomy, Phy- 
siology, and Pathology. With 434 illustrations on wood. By E. R. 
Peaslee, A. M., M. D., Professor of Physiology and Pathology in the New 
York Medical College, of Anatomy in Dartmouth College, and of Surgery 
in the Medical School of Maine, &c. &c. Philadelphia : Blanchard & 
Lea, 1857. 8vo. pp. 618. ... - 173 

XVI. The Principles and Practice of Obstetrics: Including the Treatment 
of Chronic Inflammation of the Uterus, considered as a Frequent Cause 
of Abortion. By Henry Miller, M. D., Professor of Obstetric Medicine 
in the Medical Department of the University of Louisville. With illus- 
trations on wood. 8vo. pp. 620. Philadelphia: Blanchard & Lea, 1858. 180 



BIBLIOGRAPHICAL NOTICES. 

XVII. Transactions of American State Medical Societies. 

1. Transactions of the Indiana State Medical Society, at its Eighth An- 

nual Session, held in the City of Indianapolis, May 19, 1857. 8vo. 
pp. 74. 

2. The Transactions of the New Hampshire Medical Society (Sixty- 

seventh Anniversary), held at Concord, June 2d and 3d, 1857. 8vo. 
pp. 104. 

3. Transactions of the South Carolina Medical Association, at the Extra. 

Meeting in Sumter, July 9, 1856, and at the Annual Meeting in 
Charleston, February 4, 1857. 8vo. pp. 64. 

4. Transactions of the Second Session of the Medical Society of Cali- 

fornia, convened at Sacramento, February 11, 1857. 8vo. pp. 43. 199 

XVIII. Reports of American Institutions for the Insane. 

1. Of the Friends' Asylum, Philadelphia, for the fiscal years 1855-6 

and 1856-7. 

2. Of the U. S. Government Hospital, for the fiscal year 1855-6. 

3. Of the Ohio Central State Asylum, for 1856. 

4. Of the Ohio Northern State Asylum, for 1856. 

5. Of the Ohio Southern State Asylum, for 1856. 213 

XIX. American Surgical Tracts. 

1. Remarks upon Fractures of the Scapula, with Cases presenting Strik- 
ing Peculiarities. Read before the Medical Society of the State of 
Georgia, at their Annual Meeting in Augusta, 1857. By L. A. Dugas, 
M. D., Professor of Surgery in the Medical College of Georgia. 8vo. 
pp.22. 



CONTENTS. 



9 



ART. PAGE 

2. Early History of the Operation of Ligature of the Primitive Carotid 

Artery, with a Report of Forty-eight Unpublished Cases, and a Sum- 
mary of Forty-four Cases, with Remarks by Valentine Mott, M. D. 
By James R. Wood, M. D., Surgeon to Bellevue Hospital, President 
of the New York Pathological Society, etc. etc. (Reprinted from the 
N. Y. Journ. of Med. for July, 1857.) 8vo. pp. 59. 

3. An Inaugural Thesis on Intra-Capsular Fractures of the Cervix Fe- 

moris. By John G. Johnson, of the State of Massachusetts. (Re- 
printed from the New York Journal of Medicine for May, 1857.) 
8vo. pp. 32. 

4. Surgical Cases, communicated to the Boston Society for Medical Im- 

provement, October 27, 1856. By George H. Gay, M. D., one of the 
Surgeons of the Massachusetts General Hospital. (Republished 
From the Boston Med. and Surg. Journ., Nov. 1856.) 8vo. pp. 24. 

5. Report of an Operation for Removing a Foreign Body from beneath 

the Heart. By E. S. Cooper, A. M., M. D. (Published by the San 
Francisco Medico-Chirurgical Association, as an additional paper to 
its Transactions for the year 1857.) San Francisco, 1857. 8vo. 
pp.8. - - - i", ^- - ' - - -'£22 

XX. A Collection of Remarkable Cases in Surgery. By Paul F. Eve, M. D., 
Professor of Surgery in the Medical Department of the University of 
Nashville. Including a copious index. Philadelphia: J. B. Lippincott 

& Co., 1857. 8vo. pp. 858. - - - - - - - - - 230 

XXI. Medical Lexicon — A Dictionary of Medical Science, containing a 
Concise Explanation of the Various Subjects and Terms of Anatomy, 
Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Phar- 
macy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, etc.; No- 
tices of Climate, and of Mineral Waters ; Formulas for Officinal, Empi- 
rical, and Dietetic Preparations, etc., with French and other Synonymes. 
By Robley Dunglison, M. D., LL. D., Professor of the Institutes of Medi- 
cine, etc., in the Jefferson Medical College of Philadelphia. Revised 
and very greatly enlarged. 8vo. pp. 992. Philadelphia, 1857: Blan- 
chard & Lea. 232 

XXII. On the Nature and Treatment of Club-foot and Analogous Distor- 
tions, involving the Tibio-tarsal Articulation. By Bernard E. Brodhurst, 
Assistant Surgeon to the Royal Orthopaedic Hospital, etc. etc; London: 
Churchill, 1856. 8vo, pp. 134. 233 

XXIII. Pathological and Surgical Observations: Including a short Course 
of Lectures delivered at the Lock Hospital, and an Essay on the Surgical 
Treatment of Hemorrhoidal Tumours. By Henry Lee, F. R. C. S., Sur- 
geon to the Lock Hospital, Assistant Surgeon to King's College Hospital, 
etc. London: Churchill, 1854. 8vo. pp. 232. 234 

XXIV. The Practice of Surgery. By James Miller, F. R. S. E., F. R. C. 
S. E., Professor of Surgery in the University of Edinburgh, etc. etc. 
Revised by the American Editor. Fourth American from the last Edin- 
burgh edition. Illustrated by 364 engravings on wood. Philadelphia: 
Bianchard & Lea, 1857. 8vo. pp. 682. 236 



10 



CONTENTS. 



QUARTERLY SUMMARY 



OF THE 



IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 

FOREIGN INTELLIGENCE. 



Anatomy and Physiology. 



page 

1. Researches on the Histology of 
the Nervous System. By Prof. 
Jacubowitsch. - 237 

2. On the Structure of the Nervous 
Centres. By Prof. Lenhossek. 239 



PAGE 

3. On the Nerves of the Intestinal 
Walls. By G. Meissner. - -240 

4. On the Function of the Thyroid 
Body. By Dr. Peter Martyn. - 241 



Organic Chemistry. 



5. Method of Clinically Determin- 
ing the Amount of Sugar in Dia- 
betic Urine. By Dr. Garrod. - 242 

6. Mode of Detecting Sugar in the 
Urine, and on the Different Na- 
ture of certain forms of Diabetes. 

By Dr. A. Becquerel. - - 243 

7. On the Presence of Sugar in the 
Urine of Pregnant, Parturient, 
and Puerperal "Women. By 
Theodore Kirster. - - - 244 



8. On the Elimination of Sulphur- 
etted Hydrogen by the Lungs. 

By M. CI. Bernard. - - - 245 

9. Starch from the Animal King- 
dom. By Dr. Pavy. - - 246 

10. On the Immediate Principles 
of Human Excrements in the 
Healthy State. By Dr. W. Mar- 
cet. 248 



Materia Medica and Pharmacy. 



11. Permanganate of Potash as a 
Caustic, Deodorant, and Stimu- 
lant. By Dr. D. F. Girwood. - 249 

12. On the Oriental Bath. By Dr. 
Haughton. - _ - - - 249 

13. On the Preparation of Valeri- 
anate of Ammonia of Definite 
Composition. - 252 

14. Formula for a Liquor Cin- 
chonae to replace the Wine of 
Bark. By M. Deschamps. - 253 

15. Formulae for the Gelatiniza- 
tion of Cod-liver Oil. - - 253 

16. Caustic Glycerine in Lupus. 

By Dr. Hebra. - - - - 253 



17. On a Mode of Improving Cow's 
Milk and rendering it more easy 
of Digestion for Healthy and 
Diseased Children. By Dr. Gum- 
precht. 254 

18. Mode of Preparing the Bran 
Loaf for the Use of Diabetic Pa- 
tients. By Mr. J. M. Camplin. 254 

19. The Chemical Properties of 
the Potato, and its uses as a 
general article of commerce, if 
properly manipulated. By Mr. 

J. W. Rogers. - - - - 255 



Medical Pathology and Therapeutics, and Practical Medicine. 

20. Case of Marshall Hall, with 22. On some of the Prevalent Er- 
the Post-mortem Appearances. 255 rors in relation to the Predispo- 

21. Haemophilia. By Dr. Magnus eition to Hysteria. By M. Bri- 
Huss. 259 quet. 261 



CONTENTS. 



11 



23. Asphyxia of Submersion. By 
Mr. A. T. H. Waters. - - 262 

24. Asiatic Cholera and its Pre- 
vention. By Henry McCormac, 

M. D. 263 

25. Nature, Causes, Statistics, and 
Treatment of Erysipelas. By 
Peter Hinckes Bird, F. R. C. S. 264 

26. Action of Cod-liver Oil in Chest 
Diseases. By Dr. E. Smith. - 264 



PAGE 

27. Injections of the Bronchi in 
Pulmonary Diseases. By Dr. J. 

H. Bennett. - - - - 265 

28. Treatmentof Phthisical Vomit- 
ing by Local Ansesthesia. By 
Mr. Atcherley. - ; - - 266 

29. Chloroform in Intermittent Fe- 
ver. By M. Delioux. - - 266 

30. Belladonna in Incontinence of 
Urine. By Mr. Pollock. - - 267 



Surgical Pathology and Therapeutics, and Operative Surgery. 



31. Embolic Apoplexy from De- 
tachment of Fibrinous Coagula 
in an Aneurism of the Carotid. 

By Dr. Fr. Esmarch. - - 267 

32. Case of Arterio-Venous Aneu- 
rism, which was treated by 
Ligature of both the Artery and 
the Vein. By Mr. Moore. - 268 

33. Revision of the Doctrine of 
Dislocation. By Prof. Roeser. 269 

34. Luxation of the Os Coccygis. 

By Dr. Roeser. - - - 270 

35. On the Prevention of the Ill- 
consequences of Operations. By 
Prof. Deroubaix. - 271 

36. Amputation of the Knee-joint, 
leaving the Articular Surface 
entire. By Mr. Lane. - - 272 



37. Results of the Operation of 
Tracheotomy performed for 
Croup at the Children's Hospi- 
tal, Paris, during the year 1856. 

By M. Andre. - - - - 272 

38. Treatment of Hemorrhoids. 

By Dr. Van Holsbeek. - - 273 

39. The present State of Surgical 
Science in reference to Cancer 
and its Treatment. ByxMr.Hird. 273 

40. Escharotic Treatment of Can- 
cer. By Prof. James Syme. - 274 

41. Epithelial Cancer. By Mr. 
Henry Thompson. - 276 

42. Foreign Bodies introduced into 

the Bladder. By M. Denuce. - 277 



Ophthalmology. 



43. Spasms of the Eye after Ex- 
traction of Cataract. By Mr. 
White Cooper. - 279 

44. Diphtheritic Ophthalmia. By 

M. Gilbert. - - - - 280 



45. Two Cases of Strabismus and 
very Imperfect Vision — Opera- 
tion and Cure. By Mr.Critchett. 281 



Midwifery. 



46. Quadruplet Births. By Mr. 
French. 282 

47. A New Symptom of Rupture 
of the Uterus. By Dr. McClin- 
tock. 283 



48. Two Cases of Hernia of the 
Ovaries, in one of which there 
was Periodical Enlargement of 
one or other of these Organs. 
By Henry Oldham. - - - 284 



Medical J urisprudence and Toxicology. 

49. Suicide and Intoxication by I of Laudanum ; Recovery. By 
Chloroform. By M. Chereau. - 286 I Dr. G. C. Gibb. - - - 288 

50. Death from Chloroform. By 1 52. Acute Poisoning by Phos- 
Mr. C. Heath. - - - - 288 I phorus. By Dr. Th. Nitsche. - 288 

51. Poisoning by Twelve Drachms 



12 



CONTENTS. 



AMERICAN INTELLIGENCE. 
Original Communications. 



Encephaloid Tumour weighing ten 
pounds, involving the Right Kid- 
ney of a Boy four years old. By 
M. Shepherd, M. D. - - - 291 

Case of Compound Fracture of the 
Skull, with Laceration and Loss 
of a Portion of Brain, and Com- 



pression ; Recovery. By D. J. 

McRae, M. D. - 
Confection of Cinchona as an Anti 

periodic. By D. S. Gloninger 

M.D. - 
Case of Monstrosity. By John II 

Hunter, M. D. - 



PAGE 



- 293 



- 29^ 



:94 



Domestic Summary. 



Fracture of the Neck of the Fe- 
mur ; Bony Union. By Dr. Gay. 

Disarticulation and Removal of 
nearly the Lateral Half of the 
Lower Jaw. By Dr. C. E. Isaacs. 

Simultaneous Dislocation of both 
Shoulder-Joints. By Dr. Wm. 
II. Van Buren. - 

Anomalous Situation of the Left 
Kidney. Dr. C. E. Isaacs. 



294 



295 



295 



Gun-shot "Wound of Bladder : Re- 



295 



covery. By Dr. R. II. Grinstead. 
Chlorate of Potash in Stomatitis 

Materna. By Dr. L. Faulkner. 296 
Iodide of Potassium in Leucor- 

rhoea. By Dr. Jos. B. Payne. 
Application to Sore Nipples. 
Statistical Table, exhibiting the 
Mean Height of American Re- 
295 I cruits. By Dr. Thos. Lawson. 
I Ovariotomy. By Dr. Gay. - 



296 
296 



296 
296 



THE 



AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JANUARY 1 8 58. 



Art. I. — Observations on the Causes, Effects, and Treatment of Perforation 
of the Membrana Tympani. By Edward H. Clarke, M. D., Professor 
of Materia Medica in Massachusetts Medical College. 

The following paper is founded on fifty-two carefully recorded observations 
of disease of the ear, accompanied with perforation of the membrana tympani. 
My object in bringing these observations together, and comparing them with 
each other, is to investigate the causes, course, effects and treatment of per- 
foration of the membrana tympani; or, to investigate diseases of the ear 
from the point of view of perforation of the membrane. 

It is my hope that the result of this investigation will not be altogether 
devoid of interest for general practitioners. For, we shall find by an analysis 
of the subjoined cases, that the diseases which are most likely to produce 
perforation of the membrana tympani come almost altogether under their 
observation ; and, moreover, that the most successful treatment of perforation, 
viz., the prophylactic, can be conducted by such practitioners as well as by 
specialists. 

The following observations were made on private patients, and were re- 
corded either immediately after the examination, or at the time of it. They 
were made in a clear sunlight, and by the aid of Meniere's speculum auris, 
or of the tubular speculum of Mr. Toynbee. The existence of perforation 
was demonstrated, in a majority of the cases, by the patient's blowing air, 
with a whistling rale, through the hole and out of the external meatus; or, 
when this could not be accomplished, by the use of the Eustachian catheter, 
or an examination of the perforation with a probe. 
No. LXIX.— Jan. 1858. 2 



14 Clarke, Perforation of the Membrana Tympani. [Jan. 

M. E. Triquet, in a late memoir/ has well observed that " the affections of 
the auditory apparatus are not so isolated as to be altogether unlike other 
lesions of the organism." This remark is true of the particular lesion which 
I propose to examine at the present time. For perforation is not so much a 
disease in itself as the result of disease. And moreover, the diseases which 
are the antecedents or causes of this lesion affect, for the most part, the whole 
organism primarily; the auditory apparatus only secondarily. 

Mr. Wilde, in his excellent work on Diseases of the Ear, closes an elaborate 
discussion of affections of the membrana tympani with the following remark: 
" M oreover, from the circumstance of the membrana tympani being the part 
most easily examined, being that most frequently affected, and consequently 
affording the safest means for diagnosis either for deafness arising from affec- 
tions peculiar to itself, and confined to its own structure, or which it exhibits, 
in common with other and deeper seated structures similarly diseased, it fre- 
quently affords us not only the surest but the only faithful indication for 
forming an accurate diagnosis." 3 This statement is both an inducement and 
a reason for general practitioners to study the affections of the membrana 
tympani. Of these affections, and arising from various causes, perforation is 
one of the most easily ascertained, one of frequent occurrence, and of disas- 
trous consequences to the hearing. 

Before examining the phenomena of perforation, it may be well to allude 
to the appearance, position, structure, and importance of the membrana 
tympani. It stretches across the inner extremity of the external meatus, 
separating the latter from the cavity of the tympanum. It is a delicate, 
translucent, opaline, or nearly colourless membrane. Occasionally it has a 
grayish tint, but more generally it presents a clear and brilliant hue. Its 
surface is irregularly curved and divided into two portions by the handle of 
the malleus. It sometimes happens that a ray of sunlight, striking upon 
some of these irregularities, gives the appearance of a perforation when none 
exists. Hence some caution must be exercised in deciding upon the existence 
of a perforation at first sight. What appears to be a hole may be only the 
reflection of a ray of light. 

In the healthy state no bloodvessels can be seen in the membrane. Anato- 
mists, however, tell us that they are easily made visible by a fine injection. 
They are often greatly enlarged by disease, and then give to the membrana 
tympani a bright red appearance. When a perforation heals, a circle of red 
vessels can often be seen around the circumference of the hole. I have fre- 
quently verified the remark of Mr. Wilde that, " when the membrana tym- 
pani has been perforated, a globule of air or a mucous bubble, entangled in 

1 RechercL.es Pratiques pour servir a l'Histoire des Maladies de 1'Oreille, par M. 
E. Triquet. 

2 Wilde's Aural Surgery, p. 310, Lond. ed. [p. 298, American edition. PMla., 
1853.] 



1858.] Clarke, Perforation of the Memhrana Tympani. 



15 



the aperture, pulsates synchronously with the heart and arteries." 1 This 
pulsation is produced by the beating of the tympanal vessels. 

It is important for us to remember that the membrana tympani is not an 
essential part of the auditory apparatus. A perforation through it interferes 
with its function and impairs the hearing, but does not necessarily destroy 
the latter. If the membrane is perforated, but not otherwise diseased, and 
the other parts of the ear are uninjured, the hearing power may be only 
slightly diminished. I have met with persons, carrying an aperture in 
the membrana tympani of the size of half a pea, who could hear ordinary 
conversation with ease. But this is not usually the case. A perforation is 
generally the result of disease, which has seriously affected other tissues of 
the ear besides the tympanal membrane, and by which the hearing is much 
diminished. In some instances the diminished hearing amounts to complete 
cophosis. In nearly all cases, the degree of deafness is such as to render 
perforation a most unfortunate termination of disease of the ear. The mem- 
brana tympani not only contributes to delicacy of hearing, but it serves to 
protect the cavity of the tympanum. Whenever it is perforated, the cavity 
below is exposed to changes of temperature, moisture, and other deleterious 
influences, and hence is much more likely to become diseased. Otorrhoea is 
often kept up simply by the existence of a perforation. 

Let us now proceed to an examination of the cases themselves. The ac- 
companying table, which is drawn up from my notes, presents an abstract of 
all the cases of which I have an exact record. Some of them will be referred 
to more in detail hereafter. 

1 Wilde's Aural Surgery, London edition, p. 218 [p. 216, American edition. Phila., 
1853.] 



16 



Clarke, Perforation of the Membrana Tympani. [Jan. 

Tabular View of Perforations 



6 


Sex. | 


6 
SD 
< 


1 


M. 


50 


2 


M. 


3 


3 


M. 


10 


4 


F. 


6 


5 
6 


P. 
M. 


32 
9 


7 


M. 


16 


8 


M. 


10 


9 


F. 


23 


10 


M. 




11 


F. 


10 


12 


F. 


45 


13 


M. 


12 


14 


F. 


18 


15 


M. 


5 


i'i 


M. 




17 


F. 


5 


1 s 


F. 


12 


19 


M. 




l 2o 


F. 




21 


M. 


32 


22 


F. 


14 


23 


F. 


10 


24 


F. 




25 


F. 


8 


26 


M. 


24 



® si 



Good 
Good 

Good 

Good 
Good 
Good 

Good 



Deli- 
cate 



Good 

Ave- 
rage 



Ave- 
rage 



Good 
Good 



Good 



Deli- 
cate 

Deli- 
cate 
Good 



Good 
Good 

Deli- 
cate 

Good 

Good 

Good 
Good 

Good 

(i(K)ll 



Normal 
Normal 

Normal 

Normal 
Normal 
Normal 



Throat healthy ; 

tonsils slightly 

enlarged 
Tonsils enlarg'd; 

throat healthy 



Ignorant 



Tonsils natural; 
fauces red and 
granulated - 

Tonsils enlarg'd; 
throat red and 
granulated 

Normal 

Tonsils enlarg'd; 
throat congest- 
ed 

Normal 



Throat congest- 
ed; tonsils en- 
larged 

Throat healthy; 
tonsils enlarg'd 
Normal 



Normal 

Throat healthy; 
tonsils enlarg'd 

Throat red ; ton- 
sils enlarged 

Throat red ; ton- 
sils ignorant 

Throat red and 
congested ; ton- 
sils enlarged 

Ignorant 

Tonsils enlarg'd; 

throat red and 

congested 
Tonsils enlarg'd; 

throat red and 

congested 
Normal 



Healthy 

Enlarg- 
ed 

Ig- 

Ig- 

Ig- 
Ig- 

Normal 



Enlarg- 
ed 



Ig. 



Diseas- 
ed; sup- 
pura- 
tion 

Swollen 



Healthy 
Normal 

Normal 

Normal 

Normal 
Normal 

Normal 

Enlarg- 
ed 



Enlarg- 
ed 

Ig. 

Normal 



Enlarg- 
ed 

Normal 



523 



White, with de- 
ficient wax 

Secreting mode- 
rately 

White and hard 
Healthy 

White, hard, and 
dry 

White and no 
wax 

White, hard, and 
dry 

Right, white and 
dry ; left, red 
and swollen 



Lined 
crusts : 



with 
no wax 



R., white, dry, 
hard ; L. red 
and secreting 

Both white and 
hard 



White and dry 

Red near mem. 

tym. ; sufficient 

wax ; white 

elsewhere 
Right, white and 

ho wax ; left 

healthy 
White, smooth ; 

no wax 

White ; no wax 

White ; deficient 
wax 



White; deficient 
wax 

White ; no wax 



A little red ; no 
wax 

Reddened ; no 
wax 

Red and no wax 

Red ; no wax 
Red and swollen 

Red and swollen 



White, and suffi- 
cient wax 



Ignorant 

Red and 
congested 

A suppu- 
rating sur- 
face 

Red and 
congested 
Ignorant 

Red 



Red and 
moist 

Ignorant 



Ignorant 



R., of a pale 
pink; L.. 
secreting 

Red, swol- 
len and se- 
creting 

Ignorant 

Red and 
congested 



R., secret- 
ing; L.,dry 

Red ; con- 
gested ; se- 
creting 

Red 

Red and 
congested 



Pink and 
clean 

Red ; con- 
gested 

Pink and 
smooth 

Red and 
congested 

Congested 



R., ig. ; L... 

secreting 
Red 



Red; granu- 
lated ; se- 
ci-eting 

Ignorant 



None 
None 

Fungus 

None 
None 
None 

Polypus 

None 



Polypus 
in left 
meatus 

Fungus 



None 

None 
None 

None 

None 

None 
None 

None 
Fungus 

None 

None 

Fungus 

Polypus 
None 

None 

None 



l&sl 



None 

Copious, viscid, and 
offensive ; muco- 
purulent 

Copious ; thick ; of- 
fensive 

Slight ; fetid ; waxy 
None 

Slight, and of a mu- 
cous character 

Moderate; muco-pu- 
rulent ; curdy 

Right ear none ; left 
ear purulent; 
bloody ; offensive 

Right ear none; left 
ear slight 

Right ear none ; left 
ear muco-purulent 



Copious and offen- 
sive, and thick 



Copious ; offensive : 
muco-purulent. 



Moderate and offen- 
sive in right ear ; 
none in left 

Copious ; thick ; of- 
fensive 

Slight ; thin ; mucous 

Copious ; offensive ; 
thick 



Slight ; mucous 

Copious; fetid; yel- 
lowish 

Moderate ; mucous 
Moderate ; offensive 



Copious ; purulent ; 
thick; bloody 

Copious ; offensive ; 

cheesy 
Moderate ; offensive ; 

mucous 

Moderate ; white ; of- 
fensive 



1858.] Clarke, Perforation of the Memhrana Ti/mpani. 

of the Memhrana Tympani. 



17 



I Left 
'Both 

Both 

Both. 
Left 
Both 

Both 

Both 

Both 
Both 

Both 

Eight 
Both 



Eight 

Both 
Both 

Both 
Both 

Left 

Both 

Both 

Left 
Left 

Left 

Left 



Size of a pea 

Size of half a 
pea 

Memhrana de- 
stroyed 

Size of end of 
probe 
Size of pea 

% of nienib. 
tvm. destroy- 
ed 

Size of a pea 



Eight, end of 
probe ; left, 
mem. tym. 
half destroy' d 

Both size of a 
pea 

Eight, size of a 
pea ; left, ig. 

E., mem. tym. 
% destroyed ; 
L., size of half 
a pea 

Size of end of 
probe 

Half of mem. 
tvm. destroy- 
ed 

Eight, end of 
probe ; left, 
half a pea 

Nearly whole 
of mem. tym 
destroyed. 

Size of half a 
pea 

Eight, size of 
a pin's-head ; 
L., half pea 



ignorant 
Scarlatina 

Scarlatina 

Scarlatina 

Ignorant 

Scarlatina 

Scarlatina 



Ignorant 30 yrs. 
Ignorant 5 mos 



Whole of 
m. tym. 

Ignorant 

Ignorant 

Ignorant 

Central 



Ignorant 
Otorrhcea 



Pneumonia E., below 
malleus; 
L., cen- 
tral 
Central 



Typhus fe- E, , up- 
ver per; L., 

ignorant 



E., size of pea, 

L., half a pea 
Nearly all of Scarlatina 

mem. tym. 

destroyed 
Nearly all of Ignorant 

mem. tym. 

destroyed 
E., size of half Scarlatina 

pea ; L., pea 



Scarlatina 

Ignorant 
Scarlatina 

Scarlatina 

Scarlatina 

Ignorant 
Scarlatina 

Scarlatina 



Both size of 
a pea 

Size of half pea 
Size of half pea 

Ignorant 

Ignorant 



Scarlatina 

Scarlatina 
Teething 

Ignorant 

Pneumonia 



Central 

Central 
Inferior 

Central 
Central 

Superior 

Eight, in 
centre ; 
left, in- 
ferior 

Central 

Central 
Central 



E., infe- 
rior ; L., 
central 

Central 



Central 
Central 

Ignorant 

Ignorant 



5 yrs. 

8 mos. 

16 yrs. 

6 yrs. 

10 yrs. 

7 yrs. 

17 yrs. 

18 yrs. 

4 yrs. 

6 yrs. 
6 yrs. 

12 yrs. 

IS mos. 

3 yrs. 
2 yrs. 

2 yrs. 
3| yrs. 

3 yrs. 
15 yrs. 

11 yrs. 

5 yrs. 
i yrs. 

7| yrs. 

3 yrs. 



None 



Not healed 
Not healed 



Syringe ; astrin- 
gents ; counter-irri 
tation 

Otorrhcea Astringents ; iron Not healed 
and iodine intern- 
ally 

Otorrhcea Syringe; astringents; [Not healed 

counter-irritation 
Otorrhcea with None 



pain 

Otorrhcea 



Otorrhcea and 
deafness 

Otorrhcea and 
afterwards 
pain 

Otorrhcea and 
deafness 

Deafness; after 
many years 
otorrhcea 

Otorrhcea 



Deafness 



Otorrhcea and 
deafness 



Otorrhcea 



None 



Syringe and astrin- 
gents 

Astringents; syringe; 
iron and iodine in- 
ternally 

Astringents, and ex- 
traction of growth 

Extraction of fungus; 
asiringents 



None 



None 



Syringe; astringents; 
attention to general 
health 

Syringe 



Otorrhcea Syringe and astrin 
gents 

Otorrhcea with ! Syringe ; attention to 



otalgia 
Otorrhcea 



Otorrhcea 
Otorrhcea 

Otorrhcea 

Otorrhcea 

Otorrhcea 

Otorrhcea 
Otorrhcea 

Otorrhcea 



Otorrhcea 
deafness 



Not healed 
Not healed 

Not healed] 

Ignorant 

Not healed 
Not healed 

Not healed 

Not healed 
Not healed 

Not healed 



Not healed 



general health 
Syringe ; attention to Not healed 
general health 



syringe, p. r. n. 

Syringe ; caustic ; as- 
tringents, &c. 

Syringe and astrin- 
gents 

Syringe, p. r. n. : 
counter-irritation 

Syringe; astringents: 
constitutional 

That of polypus 



iSyringe; astringents: 
I counter-irritafion ; 

constitutional 
Syringe; astringents; 

counter-irritation 



and: None 

I 



Not healed 
Not healed 

Not healed 

Not healed 

Not healed 

Not healed 
Not healed 

Not healed 

Not healed 



18 



Clarke, Perforation of the Membrana Tympani. [Jan. 

Tabular View of Perforations of 



M. 38 
18 



M 
M 
51] M. 



Deli- 
cate 
Deli- 
cate 
Good 

Good 



Ignorant 

Tonsils enlarg' d ; 
throat congest' d 
Healthy 

Normal 



Good 

Good 

Good 

Good 
Good 

Good 
Good 

Good 
Good 

Good 

Good 

Good 
Good 
Good 
Good 
Good 

Good 

Good 

Good 

Good 

Good 

Good 



Normal 



Normal 



Normal 



Tonsils normal 
throat red 
Normal 



Norm al 
Normal 

Normal 
Normal 

Normal 
Normal 



Tonsils healthy ; 
throat congest'd 
Ignorant 

Fauces red ; ton- 
sils normal 
Normal 



Ignorant 



Ignorant 



Normal 



Throat red and 
congested ; ton 
sils normal 

Normal 



Throat congest 
ed ; tonsils en 
larged 

Ignorant 



Enlarg- 
ed 

Normal 
Normal 



Normal 

Normal 

Normal 

Normal 
Normal 

Normal 
Normal 

Normal 
Normal 

Normal 

Normal 

Enlarg- 
ed 
Ig- 

Ig- 

Normal 
Ig- 

Ig- 

Normal 
Normal 
Normal 



w 

Eeddened ; no 
wax ; crusts 

Eczematous 
eruption 

White and with 
wax 

Slightly red 



Right, red ; left, 
white 



Slightly red ; no 
wax 

White ; no wax 



White and hard ; 

wax dry 
Right, white and 

hard ; left, red 

White ; wax de- 
ficient 

Right, red and no 
wax; left, white 
and wax 

Red and no wax 

Reddened ; defi- 
cient wax 



Ignorant 
Ignorant 
Ignorant 
Congested 

Ignorant 



White and 
hard 

Congested 



White and 
dry 

R., congest- 
ed ; L., do. 

Ignorant 

R, ig.; L., 
pale 

Light red 
Ignorant 



White and little Congested 
wax 



Red ; no wax 



Ignorant 



White; deficient, Ignorant 
wax 

Swollen, tender, Inflamed 
painful 

Red and dry ; no Inflamed 

wax 

White and dry; Ignorant 
no wax 

Red near mem. Ignorant 
tym. ; no wax 

Red and tender ; Ignorant 
no wax 

Ignorant 



None 
None 
None 
None 

None 

None 
Fungus 

None 

Polypus 
in right 
ear 

None 

None 

None 
None 



R. none: 
L. fun- 
gus 

None 



None 

None 

None 

Polypus 

Fungus 



Red 



Red and no wax 



Red and tender 
no wax 



Red and swol- 
len ; no wax 



Ignorant 



Inflamed 



Ignorant 



Ignorant 



None 



None 



None 



Variable ; offensive ; 
bloody 

None at time of ex- 
amination 
None 

Moderate ; offensive ; 
thick 



Slight ; mucous 



None 



Moderate ; offensive ; 
mucous 

None 

Copious and offen- 
sive in left ; mucus 
in right 

None 

Right, muco-puru- 
lent and slight ; left, 
none 

Moderate ; offensive 
and thick 

Slight ; muco-puru- 
lent 

Slight ; offensive ; 
thick 



Slight and bloody 

Slight ; mucous 
Moderate ; viscid 
None 

White ; purulent 
offensive 
Slight ; mucous 

Moderate ; viscid 

Moderate ; mucous 



Ignorant 



Moderate ; purulent 



Copious ; offensive ; 
purulent 

Moderate ; muco-pu- 
rulent 



1858.] Clarke, Perforation of the Membrana Tympani. 19 



the Membrana Tympani — Continued. 



One or both 
ears per- 
forated. 


Size and 
shape of 
perfora- 
tion. 


Following 
what. 


Position of 
perfora- 
tion. 


How long 
existed. 


First symp- 
toms. 


Treatment. 


Result. 


Both 


Ignorant 


Ignorant 


Central 


16 yrs. 


Otorrhoea 


None 


Not healed 


Eight 


Tgnorant 


Eczema 


Ignorant 


2mos. 


Eczema 


Syringe ; local sooth- 


Not healed 












ing applications 




Right 


Size of half pea 


Ignorant 


Central 


ISmos. 


Pain and then 


None 


Not healed 








otorrhoea 






Both 


~a of memb. 


R , cold wa 


Central 


RHy. 


R, pain and 


Syringe; counter-ir- 


Not healed 




tvm. destroy- 


ter inj ec- 




L. 20 y. 


otorrhoea; L., 


ritation; astringents 






ed 


tion ; L., 




otorrhoea 








scarlatina 












Both 


Ignorant 


R., a cold ; 


Central 


R., 3 


R., pain, ten- 


Syringe ; leeches ; 


Not healed 




L., ig. 




w'ks ; 


derness, and 


counter-irritation 










L., 45 


otorrhoea; L., 














yrs. 


ignorant 






Left 


Memb. tymp. 


Ignorant 


M. tym. 


30 yrs- 


Otorrhoea 


None 


Not healed 




entirely de- 


absent 










stroyed 














Left 


Memb. tymp. 


Scarlatina 


Central 


16 yrs. 


Otorrhoea 


Caustic to growth, 


Not healed 




nearly de- 








and astringents 






stroyed 














Right 


Mem. tym. % 


Ignorant 


Central 


8 yrs. 


Otorrhoea and 


None 


Not healed 




destroyed 




otalgia 






Both 


Both memb. 


Violent sy- 


Central 


6 yrs. 


Pain and then 


Polypus extracted ; 


Not healed 




tymp. nearly 


ringing, 




otorrhoea 


caustic 






destroyed 


probably 












Left 


Size of pin's- 


Cold 


Over 


9 mos. 


Pain 


None 


Not healed 




head 




malleus 










Both 


Right, oblong, 


Measles 


R., ante- 


9 yrs. 


Otorrhoea 


None to left ear; 


Not healed 




1-16 in broad; 




rior ; L., 




caustic to right, and 






left, half pea 




central 






syringe 




Right 


Mem. tym. % 


Measles 


Central 


6 yrs. 


Otorrhoea 


Astringents ; syringe 


Not healed 




destroyed 










Left 


Size of half pea 


Ignorant 


Inferior 


2 yrs. 


Otorrhoea 


Counter-irritation 


Not healed 










and constitutional ; 
















syringe 




Both 


R., % memb. 


Pertussis 


Central 


7 yrs. 


Otorrhoea 


Syringe ; caustic to 


Not healed 




tymp.; L,. % 








tungus 






memb. tymp. 
















gone. 














Left 


Size of end of 


Puncture of 


Ignorant 


lldys. 


Pain ; tender- 


Syi'inge; astringents; 


Healed 




probe ; circu- 


M. T. by 




ness ; bloody 


cathartic 






lar 


accident 






discharge 






Left 


Oblong ; supe- 


Ignorant 


Superior 


2 mos. 


Otalgia ; otor- 


Syringe 


Healed 




rior 






rhoea 




Right 


Ig.; small 


Cold 


Superior 


3wks. 


Otalgia ; otor- 


Leeches ; blisters ; 


Healed 












rhoea 


cathartics ; syringe 




Left 


Ig. ; small 


Salt water 


Anterior 


1 wk. 


Otalgia and 


Counter-irritation ; 


Healed 






bathing 






tinnitus 


cathartics ; diet 




Right- 


Large 


Ignorant 


Ignorant 


3 yrs. 


Otalgia ; otor- 


None 


Healed 








rhoea 






Left 


Small; an ob- 


Ignorant 


Ignorant 


6 mos. 


Otorrhoea and 


Syringe ; caustic ; 


Healed 




lique slit : size 








otalgia 


constitutional 






end of probe 












Left 


Small ; ig. 


Cold 


Ignorant 


2wks. 


Otalgia ; ten- 


Blisters ; syringe 


Healed 












derness; otor- 
rhoea 




Left 


Size, end of 


Ignorant 


Inferior 


2\ mos. 


Otalgia ; ten- 


Leeches ; blisters ; 


Healed 




probe 






nerness; otor- 


caustic 














rhoea 






Right 


Ignorant 


Scarlatina 


Ignorant 


8 to 10 
yrs. 


Otorrhoea 


None 


Healed 


Right 


Size of grain of 


Cold 


Inferior 


3wks. 


Pain ; tender- 


Leeches ; syringe ; 


Healed 




wheat 








ness ; otor- 


counter-irritation ; 














rhoea 


diet 




Left 


Size of end of 


Cold and 


Inferior 


4 dys. 


Otalgia; otor- 


Syringe ; counter-ir- 


Healed 




probe 


eczema 




rhoea 


ritation; cathartics 




Left 


Oblong 


Syringing 


Superior 


6 dys. 


Otalgia; swell- 


Leeches ; cathartics ; 


Healed 






ing ; tender- 


blisters ; diet 














ness 







20 Clarke, Perforation of the Memhr ana Tympani. [Jan. 

Of these fifty-two cases, it appears that twenty-eight were males, and 
twenty-four females. The preponderance of the former over the latter is not' 
large enough to show that one sex is more liable than the other to perforation. 
In a large majority of the cases, the general health was reported good : that 
is, forty-six considered themselves to be, or their friends reported them to be 
in good health. Six are recorded to have delicate health. This statement, of 
course, refers to their condition at the time they applied for advice; not to 
their condition at the commencement of the disease. 

The state of the cervical glands, and of the throat and tonsils, was not so 
satisfactory, in these cases, as that of the general health. Thus the cervical 
glands are recorded as healthy or normal in 31 cases; as enlarged or other- 
wise aifec ted in 9; and in 12 cases their condition was not noticed. Hence 
we perceive that in more than one-sixth of the cases the glands of the neck 
were diseased. The fauces appear to have been healthy in 30 cases, or more 
than one-half; and to have been affected in 15, or nearly one-third. In 7 
cases no record of the state of the throat was made. The tonsils were enlarged 
in 13 cases, or exactly one-fourth; they were healthy in 31 cases, or more 
than one-half. Their condition in the remaining 8 cases was not recorded. 
If we neglect the unrecorded instances, we find the condition of the throat to 
be stated in 45 cases ; of the tonsils in 44; and of the cervical glands in 40. 
In 15 of the 45, the throat was affected, or exactly one-third. In 13 of 
the 44, the tonsils were enlarged, or about four-elevenths. In 9 of the 40, 
the cervical glands were affected, or about one-fourth. "We cannot infer from 
this that enlargement of the cervical glands, or tonsils, or disease of the throat 
especially predisposes to disease of the ear, inducing perforation ; but we can 
infer that when disease of the ear appears in individuals of a scrofulous dia- 
thesis there is greater danger of perforation than in those of a healthier organi- 
zation. 

Now if we compare diseases of the ear complicated with perforation of the 
membrana tympani with all aural diseases, we shall obtain the following result, 
at least so far as my own observations go. I have records of 298 cases of 
disease of the ear. In 52 of these cases (which serve as a basis for the present 
paper), one or both membrana tympani are perforated. There are a large 
number of other cases which have come under my observation, and of which 
there is no record. But as I have made no selection of cases to record, it is 
not probable that the proportion of those with perforation to the total number 
would be materially changed by adding the unrecorded ones. Comparatively, 
as many of one kind were not recorded as of another. The above figures 
(52 and 298) show that 0.17, or nearly \ of all diseases of the ear, produce 
perforation of the external membrane. 

Before examining the condition of the external meatus and the cavity of 
the tympanum, let us ascertain the number of perforations in the above 
mentioned 52 cases. It appears from the table, that the right membrana 
tympani was perforated alone, 10 times; the left, alone, 19 times; and both 



1858.] Clarke, Perforation of the Membrana Tympani. 



21 



membranes were perforated 23 times. Adding 23 to the right and left single 
perforations, we find that the right membrane was perforated 33 times, and 
the left, 42 times.' This makes an aggregate of 75 perforations (in the 52 
cases). Hence, it would seem that the left ear is somewhat more likely to 
suffer from perforation than the right. As the total number of single per- 
forations is 29, and of double ones 23, it appears that in aural affections, in- 
ducing perforation, there is great danger to both ears. 

Let us next look at the condition of the external meatus. It appears from 
the table, that the meatus presented a healthy appearance with an average 
amount of wax only in 6 instances (out of the 75). In 6 cases, the walls of 
the meatus were red and swollen. In 31 cases, they were more or less red, 
without swelling. And in 32 cases, they where white and hard, without any 
cerumen or with a deficiency of it. In this statement of the condition of the 
walls of the meatus, no regard is paid to the presence or absence of otorrhoea. 
Polypus or fungous growths existed in 12 instances. In the remaining 63 
cases, there were no such growths. Otorrhoea was present in 60 out of the 75 
perforations, or in exactly four-fifths of them. In 14, it did not exist; and 
in one instance no record was made with regard to any discharge from the 
ear. 

It is an important remark that (in many instances) the above mentioned 
abnormal condition of the meatus, the existence of otorrhoea, and probably 
also of foreign growths, were consequences indirectly of perforation. For, 
when the tissues of the membrana tympani have been eaten through by ulcera- 
tion, the hole is apt to continue, after the cause which led to it has ceased to 
operate. The destruction of even a small portion of the membrane exposes 
the cavity within, of which it forms the natural protection, to the direct in- 
fluence of atmospheric changes, such as cold, moisture, etc. The effect of such 
exposure is to keep up a muco-purulent discharge from the mucous membrane 
of the cavity. The walls of the meatus are bathed and irritated by the otorrhoea. 
They become red, and swollen, and tender; or hard, cartilaginous, and in- 
sensible. The secretion of wax is interfered with or destroyed. If the otor- 
rhoea is copious and neglected, polypus or fungus is often engendered from the 
sides of the meatus or the cavity of the tympanum. Unfortunately, these 
consequences of perforation sometimes become additional causes of disease, 
and the lesions which they lead to may assume the gravest character, and 
implicate life itself. Under the best conditions, an individual with perforation 
will have imperfect hearing. But these observations go to show that the 
chance of escaping, after an aperture into the drum of the ear has been estab- 
lished by disease, with imperfection of hearing and without other lesions, is 
very slight. In only 6 cases out of the 15 was the external ear healthy — a 
proportion of less than one-twelfth. 

The condition of the cavity of the tympanum was not recorded in these 
cases so carefully as that of the meatus. In 27 cases, the appearance of the 
mucous membrane is not stated. In 2 it presented a rough and white sur- 



22 Clarke, Perforation of the Membrana Tympani. [Jan. 

face, not unlike a dense white membrane. In 14 it was pale red, and more 
or less moist. In 32, it was inflamed, considerably congested, and of a bright 
red colour. The state of the cavity leading to the white appearance just re- 
ferred to, does not often exist. In this series of cases, it occurred only twice. 
When it does occur, I am inclined to regard it as the most favourable termi- 
nation of any aural affection complicated with perforation, except the closing 
of the aperture, and the consequent restoration of the membrane to a normal 
state. In these two cases, there was no otorrhoea. The walls of the meatus 
were free from redness or tenderness, though there was a deficiency of ceru- 
men. In one of these instances, the hearing was almost entirely destroyed; 
in the other it was only moderately impaired. The patients, on the whole, 
were in a much more comfortable condition than generally falls to the lot of 
those suffering from perforation. Where neither this result is attained, nor 
the aperture healed, the next best termination is that represented by the 14 
cases, in which the mucous membrane of the cavity was of a pale red colour 
and somewhat moist. In such eases, there is no congestion of the cavity. 
There is usually no discharge ; and when there is any, it is of a mucous 
character. The patient is occasionally troubled with otorrhoea, particularly 
on taking cold, but the discharge is of short duration. Excepting a greater 
or less degree of imperfection of hearing, he is not much annoyed by the con- 
dition of his ears. The last group of 32 cases represents the state of the 
cavity which is most apt to exist with perforation. The mucous membrane 
in these cases was red and congested. Occasionally it was pushed through 
the aperture like a fungus, and not unfrequently it poured out a copious and 
disagreeable purulent secretion. 

The size of the aperture is the next point of inquiry. In 12 cases, the 
table contains no record of the size. In 4 cases, the hole was only an oblong 
slit. In 38 cases its size varied from that of a pin's head to that of a pea. 
In 21 cases, the membrana tympani was one-half destroyed, or wholly 
destroyed. With a single exception all the apertures that healed were small, 
being only about the size of the end of a probe. One large one only closed up. 

The table contains no reference to the condition of the hearing in the cases 
under consideration. By examining my notes, however, the following result 
is obtained : Assuming the ticking of my watch as the measure of the hearing 
distance, it appears that in 6 cases my watch was not heard at all. In 11 
cases, it was heard only on the pavilion of the ear. In 23 cases, it was heard 
from the pavilion to a distance of six inches. In 16 cases, the hearing dis- 
tance varied from six inches to one foot; in 15 cases, from one to two feet; 
and in 4 cases, from two to four feet. Where the membrane was perforated 
on both sides, the hearing distance was of course measured for each ear 
separately; when only the membrane of one side was perforated, means were 
taken to prevent the healthy ear from hearing the watch during the examina- 
tion. The above statement gives the hearing distance at the time when 
patients applied for relief. In many instances, even when the aperture did 



1858.] Clarke, Perforation of the Membrana Tyrrvpani. 23 

not heal, the hearing improved after treatment, by which congestion or in- 
flammation, or other morbid condition of the ear was relieved. The ticking 
of my watch can generally be heard distinctly by the healthy ear, in the day- 
time, a distance of about fourteen or sixteen feet. Comparing this distance 
with the various hearing distances just given, we can form some notion of the 
degree of deafness which generally attends perforation. In 56 of the 75 
eases, the hearing distance was a foot or less ; and in 40 cases, it was six 
inches or less. This statement confirms a remark previously made, that per- 
foration is a most unfortunate termination of disease of the ear, but it also 
shows that an aperture through the membrana tympani by no means destroys 
the hearing. 

Let us now return to an examination of the table. A comparison of the 
column which gives the age of the patients at the time they applied for relief, 
with the one which gives the duration of the disease, will enable us to ascer- 
tain the age at which the disease commenced. By such a comparison, the 
following result is obtained : The affection inducing perforation commenced 
between the ages of six months and one year, in one case only ; between the 
ages of 1 year and 10 years, in 28 cases; between the ages of 10 and 20 
years, in 6 cases; and between the ages of 20 and 50 years, in 17 cases. 
Hence, it appears that the period of life most obnoxious to this difficulty, is 
that of early childhood, or that between the ages of 1 and 10 years. More 
than half of all the cases, or 28 out of 52, commenced at this period. The 
reason of this is to be found in the fact that the exanthemata and other dis- 
eases of the general system which are apt to be followed by aural affections, 
occur most frequently in childhood. 

The length of time which elapsed before the patients applied for relief is 
a curious illustration of the common notion that diseases of the ear may be 
safely neglected. In only 7 cases out of the 52 had the disease continued 
less than a month before medical advice was sought. In 4 cases, it had con- 
tinued from 1 month to 6 months; in 3 cases, from 6 months to 1 year; in 
25 cases, from 1 year to 10 years; in 9 cases, from 10 to 20 years; and in 
4 cases, from 20 to 40 years. In some of these instances the patients had 
applied to other physicians before calling upon myself, but in by far the 
largest proportion they had not done so. 

The causes of perforation are various. " It may exist congenitally," says 
Mr. Wilde, 1 and " it may happen by accident, such as a penetrating instru- 
ment, a foreign body in the meatus, loud sudden noises, sneezing, coughing, 
or blowing the nose, diving to any great depth, falls, and blows upon the 
head. An ulcer may eat its way through, and leave from loss of substance 
a permanent opening; but the most frequent cause of perforation is otitis, or 
inflammation of the membrane in common with the lining of the cavitas 



1 Aural Surgery, p. 298, Lond. ed. [American edition, p. 287.] 



24 Clarke, Perforation of the Membrana Tympani. [Jan. 



tympani." Our present series of cases confirms this remark, 
tion of the table shows that perforation followed 



An examina- 



Scarlatina 
Cold 

Syringing the ear 

Measles 

Pneumonia 

Typhus Fever 

Pertussis 

Eczema 

Puncture 

Salt-water bath 

Teething 

Unknown disease 



18 cases, 

6 " 

3 " 

2 " 

2 " 

1 case 

1 " 

1 " 

1 " 

1 " 

1 " 
15 cases 

52 



producing 33 perforations. 
6 

ft 4 <c ' 

3 
3 
2 

" 2 " 

" 1 perforation. 

1 

1 

1 

" 18 perforations. 

. 75 



It appears from this that in 15 cases, the disease which led to perforation, 
or which preceded it, was unknown. In 20 cases the disease was measles or 
scarlatina ; that is nearly two-fifths of the perforations were produced directly 
or indirectly by the exanthemata ; or if we exclude the 15 unknown cases 
from the calculation, we find that the exanthemata led to perforation in 20 
cases out of 37, a proportion of 0.54, or more than one-half. Next to the 
exanthemata, cold ranks as the most frequent antecedent of perforation. 
Then comes improper syringing the ear, pneumonia, typhus fever, &c. 

The importance of knowing the first symptoms of approaching perforation, 
or of any disease which may lead to it, is obvious. By referring again to the 
table, we learn that the earliest symptoms of the affections which finally pro- 
duced perforation, were — 

Otorrhcea alone in 
Otorrhcea with otalgia in 
Otorrhcea with otalgia and tenderness 
Otorrhcea with deafness in 
Otorrhcea with tinnitus in 
Deafness alone in 
Eczema alone in . . 

Unknown in 
Pain alone in 



From this we learn that otorrhcea alone, or in connection with other symp- 
toms, was the first evidence of disease — the first warning of what was destined 
to cause perforation in 47 out of 52 cases. In only four of these cases, was 
there sufficient deafness accompanying the commencement of the disease to 
make it remembered as one of the first symptoms. In this statement we 
find an urgent reason for a prompt and early attention to otorrhcea, and an 
additional reason for condemning the let-alone practice, particularly after the 



24 


cases. 


12 


<« 


6 


u 


4 


it 


1 


case. 


2 


cases. 


1 


case. 


1 


<< 


1 


It 


52 





1858.] Clarke, Perforation of the Membrana Tympani. 



exanthemata, which has been too often followed. It should not only be borne 
in mind that the best time to treat an otorrhcea, and to stop it, is at its com- 
mencement, but that it often is the only warning of an insidious and ulcerative 
affection, which may speedily eat through the membrana tympani. 

The position of the perforation in these cases varies considerably. The 
aperture was central in 40 instances ; inferior, or through the lower half of 
the membrane, in 9 instances ; superior, or through the upper half, in 7 j 
anterior in 2; and unrecorded in 17 instances. Those cases in which the 
membrane was nearly all destroyed, or two-thirds destroyed, are marked cen- 
tral in the table. Of course, in such cases, the point at which the membrane 
was first ruptured does not appear. It is my impression that the rupture 
generally takes place in that part of the membrane which is opposite the 
orifice of the Eustachian tube, whenever it is produced by the pressure of 
matter within the cavity, as after scarlatina. The position does not appear 
to exert much influence upon the process of healing. For, of the 12 aper- 
tures which were healed, three were situated inferiorly; three superiorly; 
one anteriorly ; and five were not recorded. 

Let us now look at the condition of these cases after treatment. It appears, 
that of the 75 apertures, 61, or 0.82 were not healed; 12, or 0.16 were 
healed ; and in 2 cases, the result was not known. This statement refers 
only to the perforations. In a large number of those which did not heal, the 
condition of the cavity of the tympanum or meatus, or of both, was greatly 
improved by treatment. The hearing, also, was frequently increased by the 
measures which were taken to improve the condition of the ear. At the pre- 
sent time, however, we are more concerned with the result as to the apertures, 
than with the condition of the cavity of the tympanum or the neighbouring 
parts, at the close of treatment. Of the 83 perforations which followed scar-* 
latina, only one was healed. That one (No. 49 in the table) had existed for 
eight or ten years. It closed by the efforts of nature alone. It received no 
treatment at the time it healed, and consequently the process of healing was 
not observed. Of the 6 perforations which followed exposure to cold, 4 were 
healed. Three of these four apertures had not existed more than three weeks, 
and the fourth one not more than four days before treatment was instituted. 
Moreover, they were all of small size. Of the 4 perforations which followed 
improper syringing, one was healed. This one was of small size, and sub- 
jected to treatment in five days after the commencement of the attack. Of 
the 3 perforations following measles, the 3 following pneumonia, the 2 fol- 
lowing typhus fever, the 2 following pertussis, the 1 following teething, and 
the 1 following eczema, none were healed. Of the 18 perforations following 
unknown causes, 4 were healed. Of the remaining perforations which healed, 
1 was caused by puncture, and 1 by salt-water bathing. The two latter 
were placed under treatment in less than two weeks after they occurred. Of 
the four, following unknown causes, one was of large size ; it had existed 
for three years, and healed like one previously referred to, without any medi- 



28 



Clarke, Perforation of the Memhrana Tympani. [Jan. 



cal treatment. One of the remaining three arose from some aural affection 
which had existed for six months before medical assistance was called in ; 
and the other two from some disease existing for two or three months. 

The size of the aperture in ten of the twelve instances which terminated 
in a closure of the hole, was quite small, not longer than the end of a probe; 
in one, the aperture was large; and in one, the size was not observed. Of 
the sixty-one apertures which did not heal, only six were as small as the end 
of a probe. The remaining fifty-five were large, at least when they came 
under my notice. They were of the size of half a pea, or larger. 

From this statement it appears that the antecedents and the size of a per- 
foration exert a marked influence upon its healing. Perforations which are 
produced by, or which follow constitutional affections, seem to heal with great 
difficulty; while those which are produced by a local affection of the ear, 
alone, heal readily. Thus, out of forty-five perforations, following scarlatina, 
measles, pneumonia, typhus, pertussis, teething, and eczema, only one closed 
over. On the other hand, out of twelve perforations following exposure to 
cold, improper syringing, puncture of the membrane, and salt-water bathing, 
seven healed. The small size of the apertures which healed, contrasted with 
the large size of those which did not heal, confirms what we should naturally 
expect, that the smaller the size, other things being equal, the more readily 
healing can be induced. It is possible that a proper treatment, instituted 
sufficiently early, might have promoted the healing, or prevented the occur- 
rence of many of the apertures, which are recorded in the previous table as 
unclosed, but after making due allowance for judicious treatment, I have no 
doubt the general result would show that perforations following constitutional 
diseases heal with great difficulty ; those following local affections heal readily. 

The following general conclusions seem to follow from the previous analysis. 

1. Difference of sex does not exert any marked influence upon the occur- 
rence of perforation. 

2. Persons of delicate general health are not more in danger of perforation 
than the robust. Disease will rupture the membrane as readily in the healthy 
as in the feeble. 

3. Disease of the ear, occurring in individuals of a strumous diathesis, is 
more likely to terminate in perforation than in persons of a different consti- 
tution. 

4. Both membranes are more frequently perforated than either one singly. 

5. The external meatus is rarely in a healthy condition, when an aperture 
exists through the tympanal membrane. This diseased state is sometimes a 
cause, but more commonly is a consequence of the perforation. 

6. Foreign growths, like polypus and fungus, frequently co-exist with per- 
foration, and often are an indirect consequence of it. 

7. Otorrhcea is a very constant attendant upon perforation. This symptom, 
for otorrhcea is a symptom and not a disease, is not only a frequent indication 



1858.] Clarke, Perforation of the Membrana Tympani. 27 

of perforation and often kept up by it, but, in a large majority of cases, is 
the earliest warning of an insidious disease that will lead to it. 

8. The mucous- membrane of the cavity of the tympanum is variously 
affected by the existence of a perforation. It is sometimes of a pale red 
colour, and without inflammation. More frequently it is congested. Occa- 
sionally, it is congested so as to be pushed through the aperture. In rare 
instances, it is covered and protected by a white, dry membrane upon its 
surface. 

9. Quite a large proportion of all affections of the ear are complicated 
with or terminate in perforation. About one-fifth terminate thus. 

10. An aperture (after it- has existed for some time) generally occupies 
from a third, to a half, or two-thirds of the membrana tympani. The smaller 
its size, the greater is the probability and the facility of cicatrization. 

11. The power of hearing is diminished, but is not obliterated by a per- 
foration. A simple aperture of moderate size, i. e. one uncomplicated 
with disease of the cavitas tympani, or of the external meatus, produces only 
a slight degree of deafness. A simple aperture of large size, or even a com- 
plete 'destruction of the membrane, does not destroy the hearing. 

12. Perforation is most likely to occur in childhood. Its most frequent 
cause is acute or subacute otitis. It is occasionally produced by accident or 
puncture. The common causes of what might be called perforating otitis, 
are the exanthemata, exposure to cold, eczema or erysipelas of the ear, and 
improper syringing. 

13. The position of the aperture is various. When large, it is central. 

14. The condition of the ear, and the hearing, may be improved by treat- 
ment, when the perforation- itself cannot be healed. 

15. Perforations, following the exanthemata or constitutional diseases, are 
the least disposed to heal. Those following exposure to cold or local causes, 
inducing ordinary otitis, are more likely to heal. Those following puncture 
or accident, heal readily. 

Among the various subjects of inquiry suggested by the analysis of the 
previous cases, there are two or three of especial importance. These are, first, 
the course, symptoms, and treatment, prophylactic and otherwise, of perfora- 
tion following the exanthemata, or of what might be appropriately called ex- 
anthematous perforation; second, the symptoms and treatment of perforation, 
when induced by other causes than the exanthemata, or of simple acute per- 
foration ; and third, the general treatment of chronic incurable perforation. 
The propriety of discussing exanthematous perforation separately from other 
forms of rupture of the membrana tympani will be apparent as we proceed. 
Let us examine these subjects briefly in the order they are mentioned above. 

In the first place let me remark, that the importance of watching the 
condition of the ear during and after scarlet fever and measles, can scarcely 
be over-estimated. From the data upon which this paper is founded, it appears 
that nearly one-half of all cases of perforation follow the exanthemata, a result 



28 Clarke, Perforation of the Memhrana Ti/mpani. [Jan. 

which only confirms the statements of other observers. "We have also seen 
that the perforations which are produced by, or follow the exanthemata, are 
the least disposed to heal of any. These facts are urgent reasons for watching 
with extreme care the condition of the ear during and after scarlatina and 
measles, and for employing all possible prophylactic means against the occur- 
rence of so dangerous an accident as perforation. An additional and equally 
urgent reason for this watchfulness and treatment is found in the fact that a 
proper management of the ear, during the acute stage and convalescence of 
the exanthemata, will go a great way towards preventing perforation. And 
if perforation does occur, an appropriate treatment, instituted sufficiently early, 
will, in a large number of instances, enable the aperture to close up. So 
important is a proper attention to the ear during and after the diseases just 
referred to, that a physician who treats such cases and neglects to give this 
attention cannot be said to perform his duty to his patient. Indeed, I fear 
the condition of the ear is too generally overlooked during the exanthemata. 
The attention of the physician and the attendants is engrossed by the consti- 
tutional disease. If there is a slight earache, or a little discharge from the 
meatus, it is altogether neglected, or treated lightly. Perhaps the nurse is 
directed to drop some kind of oil into the ear, or to syringe it ; more commonly, 
the physician remarks that it is a matter of no consequence ; it will get well in 
a short time, if it is only let alone, and possibly adds a needless caution about 
meddling with runnings from the ear. Thus the fears of the patient and his 
friends are quieted. He gets well, but his ear continues to discharge. In 
the course of a few weeks or months, the continued discharge, or partial deaf- 
ness, or both, compel him to seek medical advice. His ears are now care- 
fully examined, and one or both membrana tympani are found to be perforated. 
The evil is done. Only palliative treatment can now be instituted for the 
relief of a lesion, which, I venture to say, might have been prevented in more 
than half the cases of its occurrence. It is the duty of practitioners to examine 
the state of the ear in all cases of scarlatina or measles. The attention of 
the patient or his attendants should be called to the ear. They should be 
told to watch it, in order to report the first symptoms of any derangement. 
Instead of having their fears quieted, they should be told that the time to 
prevent future evil consequences is at the beginning of the attack. 

Fortunately perforating inflammation of the ear does not come on without 
warning. We have already seen that in 47 out of 52 cases, otorrhcea, either 
with or without other symptoms, marked the access of disease which resulted 
in perforation. In 12 of these 47 cases, otalgia was associated with the 
discharge from the meatus. In every case which followed the exanthemata, 
otorrhcea, to which sometimes earache was added, gave warning of danger. 
The practitioner, then, who has charge of scarlatina, measles, etc., should be 
on the look out for the slightest otorrhcea, or otalgia. The nurse, or other 
attendant, should be directed to watch the ears carefully, and to report to the 
physician the first sign of moisture about the orifices of the meatus. In like 



1858.] Clarke, Perforation of tlie Memhrana Tympani. 29 

manner, any complaint of earache should be watched for and reported, and 
the occurrence of one or both of these symptoms should be the signal for a 
careful inspection of the ears. It is not difficult to examine them, nor to re- 
cognize the existence of a morbid condition in them. The services of a 
specialist are no more necessary to do this than they are to recognize the 
existence of a pneumonia or of a congested os uteri. By means of a specu- 
lum auris and a good light, the condition of the meatus and of the mem- 
brana tympani can in most cases be satisfactorily ascertained. When a sun- 
light cannot be obtained, or the patient is too sick to be placed in a position 
which will enable the sun's rays (aided by a common mirror, used as a re- 
flector), to enter the meatus, an artificial light can be advantageously substi- 
tuted. A lamp, with a common reflector attached, which can be held so as 
to throw a strong light upon the patient's ear, will answer the purpose just as 
well as any of the expensive and complex lamps for the ear which have been 
invented, and a great deal better than most of them. 

It is not to be denied that there are many cases which do not admit of an 
examination when the ear is first attacked. The patient may be too sick to 
allow of its being done. The sides of the throat and face may be so swollen 
as to nearly close the orifice of the meatus and prevent any exploration. Or 
the meatus itself may be tumefied and tender, so as to forbid the necessary 
manipulations. But after making due allowance for all such cases, there re- 
main a large number, doubtless a majority, in which an examination could be 
easily made, if the attending physician only felt the necessity of making it. 
Moreover, it is not generally the case that such an examination is demanded 
at the time when the constitutional disease is at its height. I have no statis- 
tical data by which to decide this point, but my impression, so far as I can 
recall the cases which have come under my observation, is, that in a large 
proportion of the cases of perforation following the exanthemata, the local 
affection does not begin till the acute stage of the constitutional disease has 
passed; and more than this, the local affection frequently does not appear till 
convalescence from the constitutional one is fully established. After the 
general affection has subsided, an exploration of the ear can always be readily 
made, and the extent of the local disease ascertained. 

When the membrana tympani is perforated by ulceration, following the 
exanthemata, the membrane itself is not usually, if ever, the part primarily 
affected. The disease commences either in the cavity of the tympanum or 
in the external meatus or in both. Most frequently it begins in the former. 
When it commences in the meatus it is most apt to come on during the period 
of desquamation after scarlatina, or, when the specific eruption has entirely 
receded, after measles. If it commences in the cavity of the tympanum, it 
generally shows itself at the time when the fauces are most seriously affected. 
In some cases, the cavity of the tympanum and the external meatus are 
simultaneously affected. The morbid appearances and the progress of the 
No. LXIX.— Jan. 1858. 3 



30 



Clarke, Perforation of the Membrana Tympani. [Jan. 



disease depend a good deal upon which of the two ways just indicated it 
begins. 

When the external meatus is the seat of the primary attack, its usual 
course is the following. Soon after the specific eruption begins to subside, 
perhaps a week or ten days later, or possibly while the eruption is at its 
height, the patient complains of irritation about the meatus. If not old 
enough to complain of this, he manifests it by working at the orifice, trying 
to get his finger into the passage, and to scratch and pull the ear. Presently 
a little moisture is seen about the orifice, which soon increases so as to become 
decided otorrhcea. We have already seen that in forty-seven out of fifty-two 
cases of perforation, a discharge from the ear gave the first warning of ap- 
proaching danger. Frequently the commencement of the otorrhcea is accom- 
panied with earache. Sometimes the latter is so slight as to be forgotten by 
the patient, unless it is inquired for by the physician. The discharge is at 
first slight and thin, resembling a serous secretion. It soon becomes copious 
and thicker, and is often quite offensive. There is not usually much tender- 
ness of the meatus, though in some cases, the orifice is sensitive to pressure. 
More frequently, the passage is swollen, and sometimes it is rendered sore by 
the acridity of the discharge. If only one ear is affected, there is no appa- 
rent deafness, but in reality, on carefully testing the hearing, the latter is 
found to be impaired. If both ears are affected, there is a notable diminu- 
tion of hearing. The disease, which is now fully established, may stop 
spontaneously. More often it continues indefinitely, and leads to the various 
lesions which have been enumerated. When an ear which is thus attacked is 
examined, the dermal tissue of the meatus at the commencement of the 
attack is seen to be vascular, moderately swollen, and secreting a thin serous 
fluid. No " gathering" or abscess has been formed and broken, but the 
dermal tissue pours out a thin secretion, not unlike that which floods the eye 
in conjunctivitis. The vascularity sooner or later extends to the external 
lamina of the membrana tympani, and thus the external meatus is turned 
into a secreting cul-de-sac. If the inflammation is not at once arrested, spon- 
taneously or artificially, the delicate lamina of the membrana tympani are 
eaten through, and perforation is accomplished. 

The treatment before the membrane is perforated is both simple and 
effectual. When the vascularity of the passage and the attendant discharge 
is accompanied with tenderness and earache, and the strength and age of the 
patient permit, one or two leeches should be applied to the orifice of the 
meatus. The passage should be sedulously cleansed with warm water several 
times a day. As soon as all tenderness has disappeared, or rather, as soon as 
the acute stage has passed, astringent lotions of lead, zinc, alum or tannin, 
should be instilled into the meatus four or five times a day, so as to fill the 
canal, and should be kept in contact with the inflamed surface for at least five 
minutes at a time. While astringents are used, it is desirable to keep up, 
back of the ear, a moderate degree of counter-irritation by means of cantha- 



1858.] Clarke, Perforation of the Membrana Tympani. 



31 



rides or croton oil. When the discharge is purulent and offensive, the ap- 
plication of a solution of nitrat. argenti, by means of a bit of cotton and a 
pair of slender bladed forceps, to the whole extent of the inflamed surface, 
to the membrana tympani as well as to the meatus, if the former is involved, 
is beneficial. The solution may vary in strength from ten to twenty grs. to 
the ounce, and should be applied every (second or) third day. If the otor- 
rhoea comes on without tenderness or pain, it is generally better to dispense 
with leeching, and to employ astringents and counter-irritation immediately. 
I have seen many cases get well, by simply cleansing the meatus with warm 
water two or three times a day. It should be recollected that the inner ex- 
tremity of the meatus is lower than the outer; its direction, going from 
without inwardly, is on the whole downwards. Hence there is a mechanical 
reason for the accumulation in the passage of the epithelial debris, which are 
thrown off from the meatus as well as from other parts of the body after 
the exanthemata. This accumulation is in itself a cause of irritation, and 
the getting rid of it will often be sufficient to prevent further trouble. 

When the cavity of the tympanum is the part primarily affected, the mem- 
brane is perforated in consequence of an extension of the exanthematous 
disease of the fauces, through the Eustachian tube into the cavitas tympani. 
An inflammation is set up which Mr. Wilde very properly calls exanthematous 
otitis, and which he admirably describes as follows : " In the otitis accom- 
panying scarlatina, measles and smallpox, the disease either commences in the 
mucous lining of the middle ear, or spreads into that cavity from the mouth 
or fauces, through the Eustachian tube. Sooner or later, however, the mem- 
brana tympani becomes engaged, and is ruptured, either by ulceration or from 
the pressure of the contents of the tympanum, and otorrhoea, with its long 
and varied train of consequences, ensues." 1 

The earliest symptoms of this extension into the ear are generally earache 
and deafness. The otalgia is severe ; not unfrequently it is so intense that 
the patient seems to be in agony with it, and is sometimes delirious. The deaf- 
ness is also decided, though the hearing is not completely destroyed. After 
the otalgia has continued for a few hours, sometimes for only two or three, 
more often for twelve or twenty, the membrane is ruptured; a discharge of 
pus pours through the aperture, and there is immediate relief. The relief is 
so great that the patient feels all danger to have passed ; or, if too young to 
think about it himself, his parents entertain this opinion, and look upon the 
subsequent otorrhoea as a trivial matter. Perhaps the physician encourages 
them in this notion, which a partial return of the hearing is apt to confirm. 
Occasionally the attack is more insidious. The severity of the constitutional 
disease may mark the local affection, or almost painless ulceration may eat its 
way from the fauce3 through the Eustachian tube into the tympanal cavity. 
The mucous membrane of the cavity then takes on the same unhealthy action. 



1 Aural Surgery, p. 277, Lond. ed. [American edition, p. 268.] 



32 Clarke, Perforation of the Membrana Tympani. [Jan. 

Pus accumulates, distends the membrane, and presently burst through it. A 
discharge from the meatus seems to be the first indication of the local diffi- 
culty. But even when the ear is thus insidiously attacked, there are generally 
symptoms enough to warn a physician who is aware of the danger and watch- 
ing for it. The child is seen to roll his head around as if in distress; or he 
complains of slight earache \ or he is deaf, without apparent reason ; or firm 
pressure upon the meatus gives evidence of deep-seated tenderness; or deglu- 
tition or mastication may cause pain in the ear. One or more of these symp- 
toms are generally present as indications of the approaching enemy. 

If the medical attendant, whose suspicions have been thus aroused, makes 
an examination of the ear, he will find, if the membrane is affected, more or 
less of the following appearances. The membrana tympani will have a colour 
varying from a bright and diffused scarlet to a dark pink. If the cavity of 
the tympanum is distended with pus or other fluid, and the membrane is not 
ruptured, it may be seen evidently bulging out, like an abscess, pointing. If 
the patient is old enough to inflate the cavity by a forced expiration, having 
the mouth and nostrils closed, he should be told to do so. Let the physician 
then apply his ear to that of the patient. When the cavity is inflated, he 
will hear a distinct mucous bubbling if the air enters the middle ear, very like 
the coarse crackling of a tuberculous cavity. Oftentimes the inflation will 
produce a momentary and severe pain in the ear, caused by the unusual dis- 
tension of the inflamed tissues. If the cavity is not inflated, the attempt 
alone produces pain in the ear. The fauces exhibit the various appearances 
which accompany the exanthemata. The unhealthy condition extends from 
the soft palate, laterally and upwards, as far as the mucous membrane can be 
seen. The morbid discharges, purulent, acrid and otherwise, themselves the 
debris of destroyed tissues, find an exit through the nose as well as the 
mouth, and often, as we have seen, through a rupture of the membrana tym- 
pani, into the external meatus. Additional evidence of the diseased state of 
the middle ear, can be obtained, if necessary, by pressing a finger, introduced 
into the fauces just above and back of the tonsils, up towards the ear. This 
sort of rough digital examination will cause pain in the ear as well as in the 
throat, if the former is inflamed ; and if the membrana tympani is perforated, 
it will often squeeze pus through the hole into the meatus. When perfora- 
tion has taken place, a loud whistling rale is produced by inflation of the 
cavity. This is so characteristic of perforation, that of itself it is sufficient 
to determine its existence, even if the aperture cannot be seen through a 
speculum. 

When the external meatus, the Eustachian tube and cavity of the tym- 
panum are simultaneously attacked, not an unusual occurrence, the morbid 
condition of the external meatus, already described as preceding perforation 
will be found to co-exist with the diseased state of the middle ear. 

The extent to which this exanthematous affection of the middle ear is 
amenable to treatment varies with the age of the patient, the severity of the 



1858.] Clarke, Perforation of the Memhrana Tympani. 



33 



constitutional malady, and the decision and promptness of the physician. The 
patient may be too young to admit of appropriate treatment. The constitu- 
tional affection may be so grave as to preclude even an examination of the 
ear, and still more any treatment of it. The physician may be timid or faith- 
less, and let the opportunity for treatment pass by. Fortunately the first two 
difficulties, the too tender age of the patient, and the severity of the general 
disease, do not exist in the majority of cases. It is to be hoped that the lat- 
ter difficulty is of still rarer occurrence. 

The indications for treatment are, 1st, to avert perforation by subduing 
local inflammation, altering the local morbid action, and keeping the Eustachian 
tube, and especially its pharyngeal orifice, open, so that all unhealthy secre- 
tions may find an easy egress out of the middle ear into the throat. 2d. If 
perforation must take place, to make an artificial opening through the mem- 
brana tympani, for the discharge of whatever may be pent up in the cavity of 
the tympanum. 3d. After perforation has taken place, whether artificially 
or spontaneously, to employ, immediately, all general and local means to 
bring about a healthy action of the middle ear. 4th. To induce healing of 
the perforation, when this can be done, and thereby restore the membrane to 
its integrity. 

The first indication requires a variety of measures- to meet its demands. 
When there is acute inflammation, and the general strength of the patient is 
sufficient, one or more leeches to the orifice of the ear will be found of great 
service. In many cases, however, the strength of a patient, debilitated by a 
previous constitutional malady, is not equal to the loss of blood produced by 
a single leech. Blisters behind the ear are better borne, and should always 
be applied, if there are signs of inflammation of the membrana tympani, or 
if there is otalgia. Croton oil may be substituted for cantharides, if the 
patient seems too weak to bear the latter well. The counter-irritation should 
be kept up for a week or more after the appearances of inflammation have 
disappeared. Local applications to the fauces and to the pharyngeal orifice 
of the Eustachian tube are of great importance. The character of these ap- 
plications should vary with the condition of the throat. In fact the local 
treatment, which the morbid state of the mucous membrane of the throat 
generally requires after the exanthemata, should be sedulously employed ; only 
great care should be taken to make these applications reach the Eustachian 
orifices. Solutions of muriatic acid, of the liquor sodse chlorinate and of 
nitrate of silver, have proved in my hands the most serviceable. By means 
of a sponge attached to a curved whalebone, it is quite easy to apply any 
solution to the faucial extremity of the Eustachian tube. The sponge should 
be quite small and soft. It can be easily passed back of the pillars of the 
palate and up towards the ear, and thus made to sweep over the orifice referred to . 
This accomplishes the double purpose of clearing out the opening of the pas- 
sage, and often the passage itself, and of applying a caustic or alterative 
solution to the membrane. Another application of equal importance is nasa 



34 Clarke, Perforation of the Membrana Tympani. [Jan. 

syringing. The floor of the nares enters the throat on a level with the open- 
ing of the Eustachian tube. Hence a current of water, thrown into the 
throat through the nostrils, will reach and cleanse the mouth of the Eustachian 
tube. A gum elastic bag with an appropriate pipe or nozzle is the best in- 
strument for this purpose, though an ordinary syringe will answer very well. 
The water should be directed straight back to the posterior fauces, and not 
in an upward direction towards the eye. The operation is so painless that 
children, however young, rarely object to it seriously. The injected water, 
or a large portion of it, generally passes directly into the stomach, without 
producing much disturbance. This application should be repeated two or 
three times a day in ordinary cases. "When the morbid secretions are copious 
and the throat largely affected, it is well to repeat it every three or four hours, 
during the day. As more or less of the injected liquid is swallowed, it is 
not well to employ anything which would be injurious if swallowed. Medi- 
cated liquids can be more safely applied by the sponge and whalebone, men- 
tioned above. It is sometimes convenient to use, instead of the sponge, a 
syringe with a long, delicate, curved pipe and a perforated extremity so as to 
shower the parts which it is desirable to reach. If, by these measures, inflamma- 
tion is allayed, and all morbid discharges removed from the external meatus and 
the Eustachian tubes, and the mucous membrane of the throat brought into a 
healthy condition, the practitioner will often have the satisfaction of seeing 
the cavity of the tympanum preserved from any serious invasion ; and when 
it is affected, its secretions will thus be enabled to find an outlet into the 
throat instead of into the external meatus. Catheterization of the Eustachian 
tube, and syringing through the catheter, cannot be safely employed in acute 
cases. W 7 hen the acute stage has passed, however, there is less danger from 
such an operation. 

The second indication, viz., to make an artificial opening through the mem- 
brana tympani, exists whenever it is apparent that a spontaneous rupture will 
occur, if the membrane is not punctured. The symptoms which show this 
indication to exist are the unhealthy condition of the fauces, referred to 
above, occasional or persistent otalgia, deafness, and lastly and most import- 
ant, a bulging out, or pointing of the membrana tympani itself. When this 
convexity or pointing of the membrane occurs, it can be easily recognized. 
The membrane can be seen through a speculum sticking out into the meatus, 
not translucent but opaque and perhaps reddened, and clearly just ready to 
break. The relief which follows a spontaneous rupture is well known. Equal 
relief is obtained by an artificial one. The advantages of this proceeding 
are, in the first place, that of making a clean cut through the membrane, 
which is much more likely to heal than a hole eaten through by ulceration. 
Secondly, the artificial opening can be and should be made large enough for 
the contents of the cavity to empty themselves at once into the external 
meatus. The spontaneous opening is usually a small one at first, not larger 
than a pin's head, but it gradually becomes larger and larger, until, as the 



1858.] Clarke, Perforation of the Memhr ana Tympani. 



35 



previously tabulated cases show, the whole or nearly the whole membrane is 
destroyed. The artificial opening partakes more of the character of a slit. 
Its edges fall together, when the cavity ceases to discharge, and readily reunite. 
Thirdly, the operation is easily performed; it is almost painless, and with 
moderate ease it can be done without any injury to the adjacent tissues. A 
convenient instrument for the operation is a small exploring trocar, or a long, 
slender delicate knife, double-edged at its extremitj^ or a cataract needle. 
The place of selection for the puncture should be in the inferior and anterior 
half of the membrane, just below the insertion of the handle of the malleus. 
Let a tubular speculum, that of Mr. Wilde, of Dublin, or of Mr. Toynbee, 
of London, be introduced into the orifice of the meatus. Then while the 
patient's head is firmly held, and the surface of the membrane is illuminated 
by the sun's rays or an artificial light, it is only necessary to cut through 
the membrane at the point specified. The operator should of course bear in 
mind the size of the cavity of the tympanum, and take care not to wound its 
opposite wall. There is no danger of doing this if the instrument is pushed 
slowly through the membrane, and withdrawn as soon as its delicate laminae 
are felt to be divided. 

I am not aware that aurists have generally advised puncture of the mem- 
bran a tympani in cases such as are now under consideration. The proposition, 
however, is not altogether unsupported by authority. Martell Frank, whose 
admirable treatise 1 on Diseases of the Ear has not yet been translated into 
English, states that he is frequently in the habit of puncturing the membrane 
for the purpose of applying remedies to the cavity, even when the latter is not 
filled with any morbid secretion. Speaking of catarrhal inflammation of the 
cavity, and of mucus pent up within it, he says : "We must here refer again 
to the necessity of perforating the tympanum. It is impossible, especially in 
chronic catarrh, to free the cavity from the mucus accumulated within it by 
any of the proposed remedies or applications. In such cases we regard it as 
necessary, in the first place, to perforate the membrana tympani." . . . 
"After an artificial perforation of the membrane, we have often met with a 
viscid, gelatinous, slimy mass, which was immediately forced into the external 
ear by an injection of air or water, blown through a Eustachian catheter, in- 
troduced into the Eustachian tube." ..." We have never had any 
reason in a single instance to be dissatisfied with this proceeding, and can 
emphatically recommend it, without hesitation, in most eases of chronic 
catarrh." 3 Dr. Martell Frank does not refer, in this passage, to the diseases 
with which we are now concerned, nor does he elsewhere propose perforation 
in accumulations within the cavity of the exanthemata. But his testimony is 
exceedingly valuable to the simplicity and ease and safety of the operation. 

1 Practische Anleitung zur Erkenntniss und Behandlung der Okrenkranklieiten, 
von Dr. Martell Frank. Wiirzburg, 1845. 

2 Op. cit. pp. 335-6. 



36 



Clarke, Perforation of the Membrana Tympani. 



[Jan. 



If it can be easily and safely done in one ease it can also in the other. For- 
tunately, it is not necessary to call in the aid of a specialist for the perform- 
ance of this operation. It is so easily performed, that any judicious 
practitioner can do it as safely as he can open an ordinary abscess. 

The third indication, viz., to promote as rapidly as possible a healthy action 
of the tissues, after the membrane has been spontaneously ruptured or artifi- 
cially punctured, is answered by a careful attention to the measures pointed 
out under the first indication. It is needless to recapitulate them, or to urge 
their importance. But whatever local applications are employed, the necessity 
of frequently cleansing the external meatus by syringing with warm water, 
and of cleansing also the pharyngeal orifice of the Eustachian tube by nasal 
syringing should never be forgotten. This is a prerequisite to all other 
local treatment. 

I am afraid that practitioners are too apt to forget and neglect this 
whole matter. At tbe risk of tiresome repetition, I must urge again and 
again the importance of attention to it. When otorrbcea occurs after the 
exanthemata, its cause should be carefully sought after, at the earliest possi- 
ble moment. If upon examination it is ascertained that perforation has 
taken place, the patient should not be given up as incurable, but the measures 
already indicated should be at once put in force, in order to prevent further 
injury. The sooner the local morbid condition is controlled, the less will be 
the extent of permanent local damage, and the greater will be the chance of 
a closure of the aperture. If perforation has not taken place, there is equal 
reason for employing diligently the same measures in order to prevent it. 

The means of fulfilling the fourth indication, viz., to induce healing of the 
aperture and thereby restore the membrane to its integrity, have been partly 
described already. They include all those applications which have been 
mentioned as necessary to restore the external meatus, the cavity of the tym- 
panum, the Eustachian tube, and the fauces to a healthy state. When this 
has been done, the otorrhcea checked, and the inflammation allayed, and 
when the perforation, which may still exist, is not too large, it is sometimes 
possible to make the hole grow up. But the local treatment of the mem- 
brana tympani and of the edges of the aperture, with this object in view, 
can be more appropriately considered further on. 

When the external meatus and the middle ear are simultaneously attacked, 
the treatment should of course be addressed to all the diseased tissues. The 
applications previously indicated for exanthematous inflammation of the 
meatus should be added to those for exanthematous otitis; and all of them 
should be modified so as to meet the exigencies of individual cases. 

If these statements of the importance and favourable effects of treating 
disease of the ear following the exanthemata are true, it may be asked, how 
are we to account for the large number of perforations which the previous 
table exhibits? The answer is, that most of the cases recorded in the table 
were not treated for the local difficulty till months, and more frequently years> 



1858.] Clarke, Perforation of the Membrana Tympani. 37 



had elapsed after its commencement. During the exanthemata, when that 
was the cause, little or no attention was paid to the ear; and when otorrhcea 
or otalgia first occurred, no heed was given to the warnings they uttered. 
The local disease was neglected when it should have been treated, and the 
table exhibits the result of such neglect in the lesions it records. I do not 
wish to make any sweeping assertions; and I do not say that these lesions, 
perforation among them, can always be prevented, or the integrity of the ear, 
when they cannot be prevented, always restored. But I do say that a great 
deal can be accomplished in the way of prevention and relief, by appropriate 
local treatment at the appropriate time. A great deal more can be accom- 
plished than many will be willing to believe, until they make the trial for 
themselves. It would be easy to detail a number of cases in support of these 
views, but it would extend this paper, already largely prolonged, to too great 
a length. I will only give a few as illustrations. 

Case I. — M. C, a girl, set. 7, with light hair and eyes and large tonsils, 
had measles in the summer of 1849. During the attack, she suffered several 
times from otalgia, but as it soon disappeared, no attention was paid to it by 
her friends or her attending physician. The measles went through their 
ordinary stages, and the patient convalesced favourably. During convalescence, 
a slight discharge appeared from the right meatus. It was unattended with 
pain or odour. Hoping it would subside, the parents let it alone. At length, 
when six months had elapsed, and the otorrhcea had not got well, my attend- 
ance was suggested. I found the walls of the right meatus near the membrana 
tympani, moderately red and secreting matter; the membrana tympani, 
moist, slightly vascular, and not perforated. There were no other morbid 
appearances. I directed the ear to be syringed twice a day with warm waiter, 
and after syringing, a solution of acet. plumbi, gr. iij to 3j, to be poured 
into the meatus, and kept in contact with the parts several minutes each time. 
In eight days the otorrhcea stopped, and the walls of the meatus and the 
membrana tympani were normal. 

The only remarkable point in this case is, that an otorrhcea should have 
existed so long with so slight a degree of local disease. It is possible that it 
might have stopped spontaneously; but it is equally possible that it might 
have increased, if it had not been artificially checked, till perforation had 
taken place. This case is given merely as an illustration of the way in which 
perforating ulceration of the membrana tympani following the exanthemata 
often commences, when its origin is in the external meatus. 

Case II. exhibits more clearly the early symptoms of exanthematous in- 
flammation of the external ear passage. Gr. S., a healthy boy, £et. 4, had 
measles in the spring of 1856. The eruption came out fully, and subsided 
normally. In less than a week I was able to discontinue attendance. During 
the attack, there were no symptoms of inflammation of the ear. I informed 
his mother of the danger of aural disease, and directed her to watch his ears 
carefully and let me know if there was any otalgia or the slightest otorrhcea. 
Before many days had elapsed I was sent for, and told that during the night 
previous to this call, Gr. S. was awakened by a severe earache. The pain 
continued for about half an hour, and was apparently relieved by putting 



38 



Clarke, Perforation of the 31embrana Tympani. 



[Jan. 



some warm and moist application upon the ear. In the morning his ear 
seemed to be well, and his mother said that she should not have sent for 
me if I had not requested her to inform me of any occurrence like earache or 
discharge. On examination, the walls of the meatus of one ear were found 
to be somewhat vascular, and the surface of the mem bran a tympani of a diffused 
red colour. The whole passage was moist, though not secreting largely. 
Croton oil was applied back of the ear; the passage was gently syringed ; in 
a day or two a mild solution of acet. plumbi was poured into the ear a few 
times. In less than a week, the inflammation subsided. There was no more 
otalgia or otorrhcea. The ear has since been well. This attack was mild, 
and yet if it had been neglected, it would have been very likely to end in 
perforation. 

Case III. is an example of inflammation of the middle ear as well as of 

the external meatus, and membrana tympani. M. , a healthy girl of 

three or four years old, living in the neighbourhood of Boston, was attacked 
with scarlet fever in July, 1854. The attending physician reported the child 
to have been very sick. The characteristic eruption came out fully, and 
disappeared in the usual way. The integuments and glands of the neck were 
swollen, and the fauces ulcerated. When convalescence commenced, a copious 
discharge poured from both ears, and an acrid running from the nostrils. I saw 
the child in consultation, about 10 or 12 days from the beginning of the fever. 
She was weak, irritable and restless. Her skin was desquamating freely. 
Her fauces were red and swollen, with patches of a dirty white colour, at dif- 
ferent points. This appearance extended as far up and back of the pillars of 
the palate, as the mucous membrane was visible. A yellowish secretion 
poured out of the nose and ears. Her hearing was impaired, though to what 
extent could not be accurately determined. After syringing the ears, the 
walls of each meatus were seen to be moist and red. Both membranse tym- 
pani had a diffused red colour, and were perforated. The perforations were 
small, being just large enough for matter to be seen oozing through from the 
tympanal cavity into the meatus. I advised the application of diluted muriatic 
acid to the fauces; syringing with water through both nostrils into the throat 
several times a day; syringing of the ears often enough to keep the passages 
free from purulent accumulation ; continued counter-irritation back of the 
ears; and after the lapse of a day or two, the instillation of a solution of acet. 
plumbi, three or four times a day into each meatus. The employment of 
appropriate general measures, calculated to hasten convalescence were also 
urged. I did not see the patient again, but was informed several months later 
by her physician that her recovery was perfect. The otorrhoea soon subsided. 
The apertures through the mem bran oe tympani healed, and her hearing was 
normal. The proposed local treatment was faithfully followed. 

Case IV. presents symptoms of a still graver character. My attendance 
was requested on H. B., a boy, set. 3£, residing in Boston, and attacked with 
scarlet fever in Jan. 1857. The eruption came out well and went off as usual. 
While desquamation was taking place, the throat began to swell, and large 
abscesses formed, first beneath one ear and then the other. They were lanced 
and discharged copiously. The fauces were moderately but not largely ulcer- 
ated. At one period, the renal secretion stopped entirely for 36 hours and 
then came on again. Symptoms of dropsy of the head appeared, to such an 
extent as to render recovery extremely doubtful. At length, after a conva- 
lescence prolonged for three months, he got well. But what we are especially 
concerned with now, is the affection of his ears. On the 5th day of the fever 



I 



1S58.] Clarke, Perforation of the Memhrana Tympani. 39 

lie had severe otalgia of the right ear. The orifice and walls of the meatus 
were swollen and tender, and the membrana tympani could not be seen. 
Opiate fomentations- were applied, and the earache disappeared. Two days later 
an acrid, watery discharge dripped from his nose, and at the same time an 
otorrhoea appeared from both ears. He was too sick and feeble to admit of 
any local treatment of his ears, beyond keeping them faithfully clean with the 
syringe. By the third week of the fever, he seemed to be completely deaf. 
He paid no attention to the loudest and sharpest sounds, even when close to 
his ear. As soon as his general condition admitted of a careful examination 
of his ears, I found both membranse tympani perforated. The perforations 
were large enough to allow the passage through them readily of the end of a 
common sized probe. The local treatment was the same as that of Case ill., 
except that liquor sodse chlorinat. was applied to the fauces instead of muriatic 
acid; and, on account of the extreme weakness of the patient, nasal syringing 
was not used. The meatus of each ear, however, was carefully syringed 
several times a day after the appearance of the discharge. Counter-irritation 
was employed as soon as the severity of the general disease abated. By the 
time convalescence was fully established, that is, about three months from the 
commencement of the fever, the aperture in the left membrana tympani was 
closed, and the appearance of the meatus and the hearing were normal. The 
perforation of the right membrana tympani still existed, though of such small 
size as to render its closure probable. 

Case V. is an illustration of the facility of puncturing the membrana tym- 
pani and of the benefit derived from the operation. It is extracted from Mr. 
Harvey's late work on aural diseases. 

" Two children, sisters, were brought to the author for his advice ; they were 
both suffering from otorrhoea and deafness, with perforated membrane on each 
side, the result of a recent attack of scarlatina. A brother, nine years of age, 
had been sent into the country to be out of the way of the contagion. The 
author requested that he might have early tidings if this child were attacked, 
which took place on his return home a week or two afterwards. The child was 
delirious and suffering extreme agony in the ear. On examining the meatus, 
the canal was much narrowed, and dilating it with the bivalve forceps showed 
the membrane of the tympanum red and swollen. Placing the cases of the 
other two children (who were suffering so much from the same cause) before 
the parents, the author obtained permission to puncture the membrane, an 
operation which he had long determined to perform on the first opportunity, 
being anxious, if possible, to prevent the misery he had so often witnessed. 
This was now performed on both ears with a broad-shouldered cataract needle. 
Upon withdrawing the instrument it was seen to be besmeared with purulent 
matter, and although there was not any immediate copious discharge, yet in a 
few hours matter was seen to run freely from the meatus. The child expressed 
himself as much relieved by the operation, and the result was highly satisfactory. 
The discharge continued for two or three weeks, and then ceased. The aperture 
closed on each side, and not the slightest imperfection in hearing is discover- 
able, whereas both the sisters are slightly deaf to this day, and have not yet 
got rid of the otorrhoea. The author has since repeatedly opened the tympanum 
in cases of suspected accumulations of matter from other causes, and has seen 
no reason to regret taking this step, as in every case the membrane has healed 
so readily that a repetition of the operation has been sometimes needful." 1 

I have preferred to quote the above case rather than to present one from 
my own experience, because it lends the authority of Mr. Harvey to the 



5 The Ear in Health and Disease, by William Harvey, F. R. C. S. pp. 101-2. London. 



40 



Clarke, Perforation of the Memhrana Tympani. [Jan. 



operation, as well as illustrates its beneficial results. We have already seen, 
by a previous quotation, that Dr. Martell Frank is frequently in the habit of 
performing it and with manifest advantage- 
Let us now return to the second subject suggested by the table, viz., the 
symptoms and treatment of perforation when induced by other causes than 
the exanthemata, or of simple acute perforation. This form of perforation 
seems to be essentially different from the exanthematous variety. Its cause 
is rarely of a constitutional character. The affections which lead to it do 
not generally implicate so extensively the tissues of the ear. Its progress is 
milder, and it is much more amenable to treatment. 

It may be produced, as we learn from the table, by exposure to cold, im- 
proper syringing, eczema, pneumonia, typhoid fever, accidental puncture, etc. 
Of these various causes, cold is the most frequent. When this leads to per- 
foration, it does so by setting up an inflammation of the middle ear, a true 
otitis, which, if not arrested, goes on to suppuration, involving in its action 
the various tissues of the part, including the menjbrana tympani. The latter 
is perforated, as in exanthematous perforation, by ulceration making a passage 
for the confined pus. The other causes which have been mentioned, such as 
salt water getting into the ear during a sea bath, or violent syringing, or 
pharyngitis, or pneumonia sometimes induce otitis, and thus lead to perfora- 
tion. It is perhaps needless to say that to accidental puncture of the mem- 
brane, the above explanation of the production of perforation does not apply. 

It is apparent from these remarks, that the symptoms which attend simple 
acute perforation resolve themselves into those of otitis. We should always 
bear in mind, when attending a case of inflammation of the middle ear, the 
probability of perforation, and carefully watch from day to day the condition 
of the membrana tympani. In this as in the exanthematous variety, the two 
symptoms which are of most importance as warnings of the approach of 
danger — as urgent reasons for an examination of the ear — are otalgia and 
otorrhcea. The occurrence of one or both these symptoms mark the onset of 
the attack. It is not necessary to give a detailed account of otitis, as an 
antecedent of perforation. The severe pain, the tenderness, the painful 
mastication and deglutition, the swelling and the deafness are too well known 
to require recapitulation. The points to which I wish to draw attention now 
are that these severe symptoms attend a disease which is apt to perforate the 
membrane of the ear; that when perforation takes place, all the violent 
symptoms are greatly alleviated ; and that hence both the practitioner and 
patient are in danger of being lulled into a false security, and of neglecting 
a treatment which is still important. The aperture will generally close, if 
an appropriate local treatment is pursued. If this is neglected, it will often 
remain open. 

The circumstances which have been alluded to as causes of otitis, not un- 
frequently lead to inflammation of the membrana tympani alone; that is, to 
myringitis, without the mucous membrane or cellular tissue of the middle 



1858.] Clarke, Perforation of the Memhrana Tympani. 



41 



ear being much if at all affected. This form of inflammation occasionally 
results in perforation, though it more frequently terminates in thickening and 
opacity of the membrane. When there is danger of perforation, the myrin- 
gitis partakes of an ulcerative character. A simple inspection of the mem- 
brane in a clear light is sufficient to determine whether the inflammation is 
accompanied with a deposit of lymph or with ulceration. In the former case, 
the membrana tympani presents a radiated red surface, tense, more or less 
opaque, and without any secretion; in the latter case, there is a diffused red 
surface, swollen and secreting a purulent or muco-purulent fluid. Sometimes 
a distinct spot of ulceration can be discerned on the surface of the membrane; 
but this cannot with propriety be called myringitis. Sometimes ulcerative 
inflammation of the membrane of the tympanum comes on insidiously; that 
is, without pain, but never without more or less otorrhcea. Hence the great 
importance of examining the ear whenever there is any discharge from it, 
not only after or during the exanthemata, but in all cases of otorrhcea. 

The form of insidious and painless inflammation of the membrana tympani, 
just alluded to, is too important as a cause of perforation to be passed over 
with a bare allusion. It occurs most frequently in persons of a strumous 
diathesis, or of an enfeebled constitution. A slight exposure to cold, or to a 
high wind, or to anything which irritates the ear is a sufficient exciting cause. 
Generally the cause is so slight as scarcely to be remembered at all. It is 
followed by a sensation of moderate discomfort in the ear, but without posi- 
tive pain. Little or no attention is paid to the state of the ear ; and pre- 
sently, in a day or two, or it may be within twelve or twenty-four hours, 
otorrhcea commences. This may be the first symptom which compels the 
patient to notice his ear. If at this stage, an examination is made, the mem- 
brane is found to be largely ulcerated and perhaps already perforated. The 
following case illustrates this form of perforation better than any descrip- 
tion. 

Case VI. — Mrs. A. N., an American, about 27 years old, with light hair 
and complexion, requested my attendance Jan. 25, 1857, on account of a 
sudden discbarge from the right ear. Mrs. N. was by no means robust, and 
yet enjoyed tolerable health. The glands of her neck were apt to enlarge 
when she took cold; her tonsils were larger than usual and fauces congested. 
Three or four days before the otorrhoea appeared, she was exposed to cold by 
passing through a cold passage way without sufficient protection. She felt 
the cold sensibly in her head at the time. An hour or two later she had 
some pain in the right ear. But this was very slight and. soon passed away. 
It way so slight that she did not think of it again, till a discharge commenced. 
For a day or two she was conscious of a slight degree of irritation in the ear, 
without actual pain or any other symptom. On the 24th of Jan. there was 
a slight discharge of a thin watery fluid from the ear, which on the 25rh 
became more copious and thicker. I found the meatus red, considerably 
swollen, slightly tender, not painful, and nearly full of matter. The mem- 
brana tympani could not be satisfactorily seen. A blister was applied back 
of the ear; the meatus syringed three or four times a day, and a w T eak solution 



42 



Clarke, Perforation of the Memhrana Tympani. 



[Jan. 



of acet. plumbi. (gr. ij to Sjj) instilled into the ear twice a clay. Two clays 
later, the swelling of the meatus had diminished so that the membrane could, 
be seen. A perforation was found in the lower half of the membrane, 
through which I saw bubbles of air and mucus blown by inflating the cavity. 
The malleus was in situ. The remaining portion of the membrane was of a 
diffused red colour. The discharge was of a mucous character and not offen- 
sive. The cavity of the tympanum and the Eustachian tube did not appear 
to be much implicated in the inflammation. The ticking of a watch could 
be heard only when the watch was close to the ear. Decided counter-irrita- 
tion was kept up back of the ear; the inflamed surfaces were touched every 
other day with a solution of nit. argent, (gr. xx to warm syringing was 
employed pro re na ta ; the instillation of a solution of lead was continued, 
and the strength of the solution was gradually increased to grs. x to Jj ; at 
the same time the iodide of iron was given internally, and a generous diet 
with wine or porter advised. Under this treatment, the discharge gradually 
diminished, and the meatus and membrana tympani assumed a healthy aspect. 
Ey the first of March, five weeks from the commencement of the attack, 
there was no otorrhcea, the orifice of the meatus was coated with wax, its 
walls were healthy, the membrana tympani had a small perforation through 
its inferior half, but was otherwise healthy; and the hearing on that side 
was so much improved as not to inconvenience the patient, though it was far 
from being equal to that of the left ear. A few months before this attack I 
had occasion to examine the ears of Mrs. N., and found both of them in a 
normal condition. I was, therefore, assured of the integrity of the membrane 
previous to the attack just described. 

The treatment of simple, acute perforation should vary somewhat according 
to the character of the attack which precedes it. When it is preceded by 
acute inflammation of the tympanal cavity, antiphlogistic measures should be 
promptly employed. One or two or half a dozen leeches should be applied 
back of the ear and around the orifice of the meatus ; a brisk cathartic should 
be given and repeated till the force and rapidity of the pulse are brought down; 
a rigid diet of gruel or simple farinaceous food only should be allowed ; opiates 
will often be required to allay pain and produce sleep. The local treatment 
should consist of measures calculated to allay irritation and promote the free 
discharge of any accumulation. Steaming the ear with an infusion of poppies 
or with laudanum and water, will often give great relief, particularly if ap- 
plied to the throat and fauces as well as to the ear. If the membrana tym- 
pani is seen pressed out from any accumulation in the cavity, it should be 
punctured. Whenever there is any discharge into the meatus, the latter 
should be gently washed out with warm water, often enough to prevent pus 
from accumulating in it. As soon as the acute stage is passed, counter-irri- 
tation back of the ear will be found of service. When the otitis is relieved 
by a discharge from the meatus, the care of the physician should not be in- 
termitted ; for the otorrhcea, which seems to relieve the pain, is generally an 
indication of rupture of the tympanal membrane. If the meatus is not 
swollen, the perforation can be readily seen through a speculum. If the 
meatus is swollen so as to obscure the membrane, the existence of perforation 



1858.] 



Clarke, Perforation of the Metnbrana Tympani. 



43 



can be determined by asking the patient to inflate the cavities by a forced 
expiration. If a perforation exists, the air will be heard, on auscultation of 
the ear, to pass through the aperture with a whistling rale. In case rupture 
of the membrane has taken place, the meatus should be well and frequently 
syringed out with tepid water. The local and general antiphlogistic treat- 
ment should be continued till the inflammation of the ear has subsided. In 
most cases the aperture will close without any further treatment. As soon 
as the inflammation is subdued, the edges of the hole grow together, and the 
hearing is restored. There is often a slight degree of opacity perceptible for 
several weeks after such an attack ; but this gradually disappears. 

If the membrana tympani is inspected daily, while the process of the 
closing of an aperture is going on, the redness of the membrane will be seen 
to disappear gradually. The edges of the perforation, however, remain red 
and congested for some time after the other portions of the membranous 
surface have become clear. The perforation closes, as we should naturally 
expect, by an inflammatory process. And so long as the inflammation is 
confined to the edges of the hole and does not spread over the whole surface, 
it is to be regarded as a healthy action and not to be interfered with. This 
is an important matter. For on the one hand there is danger if active and 
antiphlogistic treatment is not promptly employed, that all the tissues of the 
ear will be sc seriously affected as to destroy the hearing ; on the other hand, 
there is danger of carrying local depletion so far as to prevent the setting up 
of inflammation enough to heal an existing perforation. When an aperture 
exists, the amount and continuance of local depletion should be regulated by 
the condition of the tympanal membrane. So long as its whole surface is 
red, either local bloodletting or counter-irritation should be kept up. But 
when the redness is confined to the edges of the aperture, depletion in any 
form is more likely to do harm than good. If this local inflammatory pro- 
cess is arrested before the aperture is closed, the perforation will in all 
probability be permanent. Indeed, if the myringitis subsides suddenly, 
leaving an opening through the membrane, with its edges clear and free from 
redness, means should be taken to excite local inflammation for the purpose 
of closing the aperture. In some instances this can be accomplished. Of 
this I will speak presently. When the acute stage has passed, and the surface 
of the membrane, notwithstanding the appropriate use of depletion, retains its 
red and congested appearance, local astringents, such as the sugar of lead or 
the acetate of zinc, or an alterative astringent like the nitrate of silver, should 
be applied directly to the surface of the membrane. This can be easily done 
by instilling them into the meatus. The strength of the solution should vary 
with the circumstances of each case. It should be weak at first and increased 
daily in strength, if the desired effect of constringing the bloodvessels of the 
membrane is not produced. As soon as the redness has disappeared from all 
parts of the membrane, except from the immediate neighbourhood of the 



44 



Clarke, Perforation of the Membrana Tympani. 



[Jan. 



aperture, the astringent should be discontinued. A longer use of it would 
be likely to prevent the healing of the perforation. 

When the inflammation of the tympanal cavity has subsided, and the aper- 
ture refuses to close, it is of great importance to induce its healing, if this can 
be done. I have already alluded to the possibility of doing this. Observation 
teaches that a simple puncture of the membrane heals with great facility. We 
also learn from observation that small apertures, spontaneously induced, heal 
with almost equal facility if the diseased condition which caused them is promptly 
subdued. We have seen that a certain degree of inflammation accompanies 
the process of healing. Now when a membrane is ruptured in consequence 
of disease of the cavity or of the membrane itself, the object of the local and 
general depletive treatment, so far as the management of perforation alone is 
concerned, is to get rid of inflammation and its attendants, whether suppura- 
tion or otherwise, as rapidly as possible, and thereby bring the aperture, at 
the earliest possible moment, to the condition of a simple puncture. But as 
nature's way of closing an aperture is by means of inflammation, the inquiry 
naturally arises whether, in cases wherein a perforation remains after the 
disappearance of inflammation, it is not possible and safe to excite an artificial 
inflammation in the membrane, and thus enable the hole to grow together. 
With this object in view, I have been in the habit, for the last few years, of 
touching the edges of perforations which appeared indisposed to heal with a 
mild solution of nit. argenti or of iodine. The application has been followed 
in a short time by a red blush around the edge of the hole, and in repeated 
instances by a gradual approximation of its sides, till at length they united, 
and the membrane was restored to its integrity. Mr. Wilde alludes to this 
method of treating apertures in his late work, 1 but does not give to it the 
prominence which it seems to me to deserve. He employs for this purpose 
the solid lunar caustic. In this form nitrate of silver is more apt to act as a 
pure caustic on the membrane, destroying its tissues, than as a stimulant. I 
have found more advantage from employing a solution of lunar caustic, of a 
strength varying from a scruple to a half drachm to the ounce. Lugol's 
solution of iodine may be employed for this purpose. My own experience, 
however, leads me to prefer decidedly the action of nitrate of silver. 

The easiest way of applying such a solution, is by means of a bit of cotton 
wrapped around the end of a delicate pair of long and slender bladed forceps. 
The cotton should be thoroughly saturated with the solution. In making the 
application, the cotton should not be thrust through the hole roughly, but 
gently touched upon the surface of the membrane close to the edge of the 
aperture. Scon after the application, the edges of the hole will be seen to 
redden, as if irritated. If this effect is not produced, the solution should be 
again applied, and the application repeated a third or fourth time, if neces- 
sary, so as to induce a slight degree of irritation. Sometimes an amount of 



1 Op. cit, London ed., p. 303. [Am. ed., p. 292.] 



1858.] 



Clarke, Perforation of the Membrana Tympani. 



45 



inflammation is excited, which threatens to involve the whole membrane. 
This, however, can be easily controlled by a blister behind the ear, or by 
applying a leech to the orifice of the meatus. More generally, there is 
greater difficulty in exciting a sufficient degree of inflammation than in pro- 
ducing too much. The frequency of the application should be regulated by 
its effect. If but little irritation is produced, it should be repeated every 
day or every second day ; if the effect is more marked, every third or fourth 
day will be enough. In favourable cases, two or three applications are all 
that is requisite to enable the aperture to close up. While this treatment is 
going on,r he membrane should be carefully watched ; and if, as sometimes 
occurs, there is any disposition on the part of the aperture to enlarge instead 
of contract, the local stimulating applications should be discontinued. 

The cases of perforation in which this treatment can be advantageously 
adopted, are those in which there is no suppuration or discharge from the 
middle ear ; in which the aperture is not large ; and lastly, in which no great 
amount of thickening or other organic changes have taken place in the mem- 
brane or the adjoining tissues. While suppuration is going on it is obviously 
impossible and probably would be undesirable to heal an aperture which affords 
an exit for the discharge. If the hole occupies more than one-fourth of the 
surface of the membrane, there is not much chance of making it close up ; if 
it is of that size or smaller, and other circumstances are favourable, it can 
sometimes be induced to heal. Organic changes, such as thickening of 
the membrana tympani, unhealthy conditions of the mucous membrane of 
the cavity, etc., interfere with the growing together of an aperture. When, 
moreover, a perforation, of whatever size, has existed for several months, after 
all inflammation, suppuration or discharge has ceased, it is very unwilling to 
heal, probably owing to the existence of organic changes, which are out of 
sight in the cavity of the tympanum. Hence the importance of commencing 
this treatment as soon as the membrane is prepared for it. In some rare in- 
stances, I have seen perforations heal which had existed for a year or more. 
Cases No. 45 and 49 of the table are of this sort. 

We have only space to present one or two cases in illustration of these re- 
marks. The first one is interesting both on account of the length of time the 
perforation had existed, of the facility with which it closed, and of the perfect 
recovery of the hearing. 

Case YII. (No. 48 of the table). Mr. J , a teacher in the University 

at Cambridge, set. 23, with light hair and eyes, excellent general health, and 
no enlargement of the tonsils or cervical glands, requested my advice in March, 
1852. He stated that two and a half months previously he was attacked with 
what, from his account, was probably otitis of the left ear. The pain at the 
time was excessive. It was relieved, however, by a discharge from the meatus. 
Soon after he called upon a physician who told him that the membrane of his 
ear was perforated. The fact was made evident enough by his being able to 
force air through the hole. He was ordered an acetate of lead wash for the 
ear; blisters were put on back of the ear; and by the advice of a second 
No. LXIX.— Jan. 1858. 4 



46 



Clarke, Perforation of ike Membrana Tympani. [Jan. 



physician, an issue was opened on the arm. The discharge ceased, but he 
was deaf on the left side, and his ear felt uncomfortable. When I saw him, 
I discovered a perforation situated below the insertion of the malleus, and in 
the anterior portion of the membrane. It was of the size of the head of a 
large probe. The walls of the meatus were slightly red and also the remain- 
ing surface of the tympanal membrane. There was a slight mucous discharge. 
The perforation was not only evident to the sight, but bubbles of air and mucus 
were seen to be blown through it by a forced expiration. The edges of the 
hole were touched in the way already described with a solution of nitrate of 
silver, gr. xx to £j ; and at the same time a leech was applied to the orifice of 
the meatus. A mild solution of the subacetate of lead was instilled into the 
meatus twice a day. Three days later, the edges of the hole were again 
touched with caustic; and after another interval of three days, the application 
was repeated for the third and last time. The diffused red hue of the mem- 
brane disappeared after leeching. The astringent wash was used till this diffused 
redness was no longer visible. In twelve days from the first application of 
caustic, the aperture was completely closed. The inflation of the cavity was 
distinctly heard, but no air could be forced through the membrane. There 
was no whistling rale. The hearing was completely regained. More than a 
year later I made a careful examination of the parts. There was no trace 
of the previous disease visible, and no cicatrix to mark the situation of the 
perforation. The meatus and membrane were in every way normal. 

The following case illustrates the facility with which a tympanal aperture 
closes, when it has existed for some time, if the affection which led to it is 
relieved. 

Case YIII. — U. F., an American lad, aet. 6, was brought to me for advice 
on account of an otorrhoea, complicated with an eruption about the ears. Kis 
general health was good. He had light hair and eyes, but no glandular 
swellings about the neck, nor other indications of a scrofulous diathesis. Two 
years previously I had treated him for a slight inflammation of the dermal 
tissue of the meatus, accompanied with otorrhoea, from which he rapidly re- 
covered. About four days before the last attack he took cold. His throat 
was sore, and he had what his mother supposed to be influenza. In a day or 
two he complained of earache. The otalgia was relieved by a discharge from 
both ears. Simultaneously with the otorrhoea, an eruption appeared in and 
around the orifice of each meatus. The otalgia did not return after the com- 
mencement of the discharge, but he was quite deaf. I found a patch of 
eczema on both ears, which extended on each side outwardly into the hollow 
of the concha, and inwardly quite into the meatus. Each meatus was filled with 
purulent and moderately offensive matter. There was some tenderness on 
pressure. The fauces were congested, the tonsils slightly swollen, and a dis- 
charge was running from the nose. After syringing, the walls of the meatus 
were found to be red and swollen. Both membranse tympani, as far as they 
could be seen, presented a radiated red appearance. The existence of perfora- 
tion was not demonstrable. 

Counter-irritation was employed back of both ears; syringing was ordered 
pro re nata; a mild cathartic given, and an ointment of lard, glycerine and 
lead applied to the eczema. Two days later, the swelling of the passages 
had diminished so as to admit of a better view of the tympanal membranes. 
A perforation of the size of the blunt end of a probe was discovered just 
below the insertion of the malleus on the left side. Its existence was proved 



1858.] 



Clarke, Perforation of the Membrana Tympani. 



47 



by inspection, by the appearance of globules of air in the discharge, and by 
seeing liquid matters pushed through the hole, when the patient blew his 
nose. Decided counter-irritation was kept up behind each ear. In two or 
three days a solution of acet. plumbi, gr. iv to ^j, was instilled into his 
ears, several times a day. In seven days the eczema disappeared. The 
otorrhoea ceased in a day or two later. In twelve days from the commence- 
ment of the treatment, the aperture closed, and soon after, the hearing was 
restored to its natural condition. In this case, the closure of the aperture 
occurred so soon after the resolution of the inflammation and the cessation 
of the discharge, that the application of caustic was not deemed advisable. 
It should be added that the inflammatory affection of the fauces and nose 
disappeared, paW passu, with the subsidence of the aural disease. 

The next case is a remarkable instance of the spontaneous healing of a 
large perforation. It shows what the restorative powers of nature are capa- 
ble of, and is an encouragement to endeavour to imitate her processes, in 
cases of perforation, where the prospect of a growing together of the hole is 
by no means flattering. 

Case IX. — (No. 45 in the table.) J. F., an American, set. 26, with ex- 
cellent general health, was attacked with tenderness, pain and swelling of the 
right ear, in July, 1850. He had suffered, for several years, from occasional 
and offensive otorrhoea of the same side. The attack, just referred to, was 
quite a severe one, and accompanied with cerebral symptoms. He was 
leeched, blistered, freely purged, and kept upon a low diet. As soon as the 
swelling of the meatus had subsided sufficiently to admit of an exploration 
of the passage, I discovered a polypus adhering to the upper wall of the 
meatus. This was easily removed. Its root was freely cauterized, and it 
did not return. A large perforation was now apparent through which the 
patient forced air and bubbles without difficulty. It is unnecessary to give 
the details of treatment. At the end of three months, the inflammation and 
swelling were gone. The perforation remained, but in other respects the ear 
had recovered. I gave the patient some necessary directions with regard to 
the care of his ear, with especial reference to the perforation, and dissuaded 
him from further treatment. In Sept., 1851, a year later, he called upon 
me for advice on account of slight vertigo with uncomfortable sensations in 
the same ear. I was surprised to find, on examination, that no perforation 
existed. The aperture was healed. The surface of the membrana tym- 
pani was clearly visible, but the membrane itself was opaque and almost 
white like paper. The process by which the aperture was filled up had 
thickened the membrane. He was moderately deaf on that side ; but not- 
withstanding this, his ear was in a much better condition than could have 
been expected. 

I do not mean to imply, by the preceding remarks, that either acute or 
chronic perforations can always be healed. On the contrary, there are a 
great many which will refuse to close up, under the most careful management. 
I have repeatedly tried to stimulate the edges of old perforations, and excite 
inflammation enough to induce this closure, and found my efforts unavailing. 
But I have also had the satisfaction of seeing many grow together, after local 
treatment, which several years ago, I should have regarded as incurable. 
Chronic cases are the most unsatisfactory to treat. Acute cases are more 



48 Clarke, Perforation of the Membrana Tymjpani. [Jan. 

easily controlled. As I have already insisted, the local management of acute 
perforation is all important. When an appropriate treatment is instituted 
sufficiently early, it will be found that a majority, instead of a minority of 
cases, will terminate in a complete restoration of the membrane. The cases, 
which have been given in detail, are all of them favourable. They were 
selected on that account. Unfavourable cases will readily suggest themselves 
in abundance to any one, and need not be detailed. The object of giving 
them is to show, not what can always be accomplished, but what can frequently 
be accomplished. 

These remarks naturally bring us to the third subject of inquiry, suggested 
by the analysis, viz., the treatment of chronic and incurable perforation. 
When disease of the ear results in perforation of its tympanal membrane, 
and the aperture, either on account of its size or from other causes, refuses to 
heal, it is not safe for the patient to neglect his ear, as if it were an organ of 
no further use to him, or one with some incurable malady, which does best 
when let alone or least cared for. Neither should any physician, when con- 
sulted on account of deafness, which on examination he finds to be caused, in 
part at least, by this lesion, advise the patient to do nothing. It is very true 
that there may be no use in trying to induce healing of the perforation. It 
might be dishonesty or quackery to hold out promises of restoration of hear- 
ing. Yet the ear should have especial care, on account of its imperfection, 
and the dangers to which its imperfection exposes it. 

The membrana tympani, besides other offices which it fulfils, serves as a 
protection to the delicate tissues and machinery of the middle and internal 
ear. When the membrane is ruptured, and especially when, as in most in- 
curable cases, the perforation is of large size, this protection is taken away. 
Inflammation is much more likely to occur in the mucous membrane of the 
cavity in consequence of external changes of temperature. Particles of dirt, 
cold water, and foreign substances of various sorts, are more likely to get into 
the cavity of the tympanum, and produce serious trouble there. Patients 
themselves frequently persist in pouring into the meatus all sorts of oils, 
essential as well as fixed oils, and sometimes even substances like brandy and 
lye, and laudanum, and tobacco infusions, and even urine, for the purpose of 
"curing deafness." These articles, generally some patent nostrum, or the 
recipe of an old woman, or an Indian doctor, are of course poured through the 
aperture into the middle ear. Some of the severest instances of agonizing pain 
and of dangerous inflammation, with cerebral symptoms, which I have ever 
witnessed, have been caused in this way. It is a physician's duty, in cases of 
perforation, to guard his patient as far as possible, against these sources of 
danger, as well as to teach him how to take care of his infirm organ. 

The treatment of incurable perforation, then, is of two kinds: first, the 
prophylactic treatment, or the care of a perforated membrana tympani ; 
secondly, the prompt treatment of any affection which complicates perforation. 
Let us examine these points briefly in inverse order. 



1858.] Clarke, Perforation of the Membrana Ti/mpani. 



49 



Perforation is frequently complicated with inflammation of the dermal 
tissue of the meatus; with polypus, or fungoid growths; with congestion, or 
catarrhal inflammation of the mucous membrane of the tympanal cavity ; and 
it may of course be complicated with other aural affections. The above are 
the most frequent. They are generally attended with otorrhoea. Sometimes 
there is a slight, inodorous, but constant mucous secretion, which pours 
through a perforated membrane, and which seems to be kept up by the ex- 
posure of the cavity to the external air. But from whatever cause the otor- 
rhoea may proceed, the meatus should be kept as free from any morbid 
secretion as possible. Gentle syringing with tepid water should be practised 
often enough, whether it be done once a day or half a dozen times a day, to 
keep the ear passage clean. No unhealthy discharges should be allowed to 
remain in contact with the undestroyed portions of the membrana tympani, 
or to burrow about in the tympanal cavity, or in the mastoid cells. The use 
of the syringe should be continued as long as the discharge exists, whether 
the latter continue for a week or two only, or for years. Patients should be 
instructed upon this point. They should be told that a perforated membrane 
is apt to keep up a discharge, and that they must not be weary of removing 
it. If they omit cleansing the ear, under the notion that it does no good — 
that the ear will do just as well without it, they expose themselves to 
the danger of an extension of the disease, and possibly to the danger of 
serious or fatal cerebral complications. Whatever other treatment besides 
syringing may be necessary, will depend upon the condition of the ear. 
Polypus, inflammation of the dermal tissues, catarrhal inflammation of the 
cavity, &c, should be treated in the same way as if perforation did not exist. 
It is not within the design of this paper to describe such affections or their 
treatment. If there are no complications, no local treatment beyond occa- 
sional syringing when there is a discharge, is needed. If there is no otorrhoea, 
the syringe should not be used. 

The prophylactic treatment, or the constant care of a perforated membrane, 
is not less important than the management of any affection which may com- 
plicate it. A perforated membrane is an imperfect protector of the middle 
ear. The watchfulness of the patient should make up for the imperfection of 
the organ. The constant wearing of wool or cotton in the orifice of the 
meatus is more likely to be injurious than beneficial. It prevents a free and 
healthy circulation of air in and out of the meatus, and confines in the passage 
any discharge or unhealthy secretions which may accumulate there. But 
whenever a person with an aperture through the membrane is exposed to high 
winds or to unusual cold, or to draughts of air about the head, or to driving 
mists at any season, whether on land or sea, he should use some means of 
artificial protection for the affected ear. In such cases a plug of wool will 
answer to keep off the temporary exposure. A pad of silk or cotton, adapted 
to the hollow of the concha, which may be applied or removed at will, is 
better still. Cold water should never be poured into the ear. Whenever a 



50 



Clarke; Perforation of the Membrana Tympani. 



[Jan. 



river or sea bath is taken, the meatus should be carefully closed with cotton 
or other substance, so as to completely prevent the entrance of water. In 
short, all irritating substances should be carefully excluded. And especially 
should the patient be warned not to pour into the passage oils or washes, or 
other liquids, with the vain hope of regaining his hearing. Nothing of that 
sort should be used, except by the prescription of a physician. 

Of late years, various attempts have been made to find a substitute for a 
destroyed or perforated membrane. Mr. Yearsley of London published in 
the Lancet in 1848, several articles upon the advantages resulting from 
applying a pellet of moist wool over a perforation, or of substituting it for a 
destroyed membrane. Since then Mr. Toynbee has endeavoured to make a 
substitute for the membrane out of vulcanized India rubber. He has invented 
several ingenious instruments for the application of his artificial membrane, 
and has not only published a series of articles explaining his discovery, 
but has published an account of it, with cases, in a separate pamphlet or 
monograph. Mr. Nottingham, of Liverpool, in his recent work on Diseases 
of the Ear, gives a number of cases illustrating the advantages resulting from 
such an artificial substitute. I have made the same application myself in a 
large number of instances, but my observation does not confirm the enthusi- 
astic statements of Mr. Yearsley and Mr. Toynbee. I should speak of its 
advantages in much soberer language. 

It must be conceded, however, that in many cases of perforated membrane, 
the stopping of the hole by any unirritating material, such as moist cotton, 
or wool, or India rubber, or gutta percha, or even paper, improves the hearing. 
By rendering the partition between the meatus and the cavity of the tym- 
panum complete, by absolutely shutting off the latter from the former, the 
hearing is generally improved. Whatever may be the physiological explana- 
tion, the fact is indubitable. The improvement is sometimes moderate, and 
sometimes decided. But a great hinderance to the use of an artificial sub- 
stitute is the difficulty of applying it, and after it is applied, of making it 
keep its position. Unless the patient can apply it himself, as a pair of spec- 
tacles can be put off and on, it is of little practical value. No person could 
go to a physician or aurist every day to have his hearing apparatus adjusted. 
After it is applied, it is apt to slip out of place. These practical objections 
to the employment of an artificial substitute for the membrane have not yet 
been overcome. When they are overcome, a substitute for the lost membrane 
will be of great value. A case occurs, now and then, of an individual who 
easily acquires the power of adjusting the substitute himself, and who is 
enabled to keep it in situ. For such persons I have found the simple pellet 
of cotton or wool decidedly preferable to the India rubber membrane of Mr. 
Toynbee. 

The conditions which are most favourable to the use of moist cotton or other 
substitute for the membrana tympani have not yet been clearly recognized. 
So much of the auditory apparatus is hidden from view that it is impossible 



1858.] Clarke, Perforation of the Memhrana Tymjpani. 



51 



to determine these conditions by inspection alone. The following appear to 
be necessary. The perforation should be larger than a mere puncture through 
the membrane ; it should occupy a quarter or a third of the membranous 
surface. On the other hand, the membrane should not be entirely destroyed. 
At least a bare rim, marking its insertion into the bony meatus, should be 
present. The Eustachian tube should be open. There should be a moderate 
amount of secretion from the cavity of the tympanum, enough to moisten it, 
but not enough to clog the parts with the discharge. There should not be a 
congested or granulated state of the mucous membrane of the cavity. Acute 
inflammation, or fungus, or polypus, should not exist. In a few words, the 
conditions, or at least some of the conditions, necessary to the use of any 
artificial membrane, are a hole of moderate size, patency of the Eustachian 
tube, moisture of the cavity, the absence of acute or chronic inflammation 
and of foreign growths. Moreover, the cotton or wool should be accurately 
adjusted to the perforation. A pellet not much larger than the hole should 
be selected. It should be moistened in water, or in glycerine and water. In 
some instances, olive oil answers a better purpose than anything else. Ex- 
periment alone can determine which is best. The less the pellet is worked 
over by the fingers in preparing it the better. A very convenient way of 
applying it is to pass a linen thread through the centre of a bunch of 
cotton or wool, and tie it so as to hold the bunch by the thread. The free 
ends of the thread can then be passed through a small and hollow silver or steel 
tube. A tube of the size of a large wire or of a probe is large enough. By 
means of the thread it is easy to keep the pellet close on the end of the hollow 
tube, and carry it down through the meatus to the perforation. When it is 
accurately adjusted, the tube is withdrawn and the cotton left. The thread, 
which lies in the meatus, is a convenient means of removing the pellet when 
it is desirable to do so. The operator can generally learn, by the sensations 
of the patient, when the cotton is properly adjusted. The patient feels that 
it is in the right place, and exclaims that he hears better. 

As I have already remarked, too much must not be expected from this 
substitute for a membrana tympani. In many cases, it cannot be applied. 
In many cases where it can be applied it is of no use. In other cases, where 
appropriate conditions exist, it is of service. In a few cases, the advantage 
is very great. If it ever acts as a source of irritation in the passage, it should 
not be used. Whenever it is employed, it should be removed at night and 
a fresh one applied the next morning. 

It is now time to bring this long article to a close. It has attained a length 
which the writer was far from anticipating when it was commenced. If it 
should serve in any degree, however slight, to draw the attention of observant 
physicans to the study of a lesion of the auditory apparatus, so important as 
perforation, and especially to perforation as one of the complications of the 
exanthemata most likely to occur, and often of possible prevention or relief, 
it will accomplish all that he expected from it. 



52 



Flint, Pulmonary Tuberculosis. 



[Jan. 



Art. II. — Clinical Report on Pulmonary Tuberculosis; giving an abridged 
account of Twenty-Four Cases of Arrested Tuberculosis, with Remarks on 
the Management of the Disease. By Austin Flint, M. D., Professor of 
Clinical Medicine and Medical Pathology in the University of Buffalo, 
N. Y. 

Few subjects in practical medicine are more important than the manage- 
ment of pulmonary tuberculosis. It is sufficiently established that recovery 
from this disease may take place even when the lungs have been damaged to 
a considerable extent. This has been settled by autopsical researches, taken 
in connection with the ante mortem history, in numerous instances coming 
under the notice of competent, trustworthy observers. Since the means of 
diagnosis have been rendered precise and even demonstrative by the modern 
methods of physical exploration, clinical observations have shown that in a 
certain proportion of cases the deposit of tubercle, after a longer or shorter 
period, may cease, and the destructive processes incident to the progress of the 
disease, either be suspended or fail to occur. In short, the affection may be 
arrested ; and if the injury done to the pulmonary organs be not completely 
repaired by the cicatrization of cavities, absorption of the exuded material, or 
by other modes, the condition of the patient in consequence of the non-pro- 
gression of the disease is compatible with comfortable health. Now, what 
measures of management are most likely to effect or favour the arrest of pul- 
monary tuberculosis? Does it lie within the resources of medical art, by 
judicious measures of management to accomplish or promote this object? If 
there are not any known efficient means for attaining directly to this end, is 
it true that certain therapeutical agencies which have been, and still are em- 
ployed, to a greater or less extent, in the management of this disease, exert 
an unfavourable influence, and hence the object may be indirectly favoured by 
avoiding them? I shall endeavour in this paper to contribute somewhat to 
the knowledge on which must rest our ability to answer these questions. I 
propose to select from my clinical records the cases of pulmonary tuberculosis 
in which the histories afford proof of an arrest of the disease, or a progress 
so slow as to be inappreciable. I shall present a brief account of each of these 
cases, and, afterward, institute a comparison as regards the points pertaining 
to management in which more or less of the cases agree. In these points of 
agreement lie the means which, it may be supposed, have been concerned in 
arresting the progress of the disease. Is it found that certain remedies en- 
tered into the treatment of all, or the greater part of the cases, then it is a fair 
presumption that to one or more of these remedies the favourable result is due 
in a greater or less degree, with this important provision, viz., that they have 
not entered into the treatment of these cases in common with those in which 
the disease has advanced steadily to a fatal termination. The same remark is 



1858.] 



Flint, Pulmonary Tuberculosis. 



53 



alike applicable to measures of management relating to diet and regimen. The 
great question, in short, is, in what particulars do these cases, as regards 
management, agree among themselves and differ from other cases in which 
the progress of the disease is unfavourable? Other questions will arise in 
connection with the comparison, which 1 will not now anticipate. 

The following inquiry may properly be premised: What constitutes ade- 
quate evidence of arrest or non-progression of the disease? In the living 
body we can judge concerning these points only by means of local and general 
symptoms, and, in some measure, by physical signs. With our knowledge of 
the laws of pulmonary tuberculosis, if a patient present for successive weeks 
and months a marked improvement in the symptoms referable to the lungs; 
viz., cough, expectoration, respiration, and also in the condition of the 
body as denoted by increase of weight and strength, the disease is certainly 
not progressing, and may be retracing its steps toward recovery. The latter 
may be considered to have taken place when pulmonary symptoms have been 
wanting for several months and a healthy condition of the body is restored. 
A comparison of the results of physical exploration before and after the arrest 
of the disease, will furnish evidence, first, of the correctness of the diagnosis, 
and, second, of the improvement which has taken place in the state of the 
pulmonary organs, as well as of the permanent effects of the disease upon 
these organs. 

There are various pathological questions relating to tuberculosis which are 
not only interesting but important in their practical bearings. Such, for ex- 
ample, are, the nature of the exudation process, whether inflammatory or other- 
wise; the capability of the deposit re-entering the vessels by absorption; the 
relations of the local affection to a constitutional cachexia and diathesis; the 
retrogressive changes which the exudation undergoes, and the different modes 
in which recovery is effected. It does not fall within my plan to discuss any 
of these questions or others of a like character. I purpose, at present, to 
study the management of the disease exclusively in a clinical point of view, 
and to restrict myself to the cases which have come under my own observa- 
tion. The cases which I am able to gather exemplifying arrest of the disease 
are twenty-four in number. The collection is not large, but in view of the 
well known intrinsic tendency of the disease (according to past experience) to 
advance steadily onward to a fatal termination in the vast majority of cases, 
the number is not insignificant. It is highly probable that my records would 
have supplied a greater number, were it not that in a pretty large proportion 
of the cases of the disease coming under my notice, the patients were from a 
distance, and I have not taken pains to procure information respecting the 
subsequent history. As it is, the collection is, perhaps, sufficiently large to 
render tedious an account of the cases severally. I shall endeavour to obviate 
this as far as possible by condensing the histories and omitting details which 
are not important with reference to my present object. The value to be 
attached to the account of these cases individually, and to the results of an 



54 



Flint, Pulmonary Tuberculosis, 



[Jan. 



analysis of them, will of course depend on the correctness of the diagnosis. 
Until within late years, instances of supposed recovery from phthisis were un- 
reliable in consequence of the want of certainty in the means of determining 
the presence of the disease. This uncertainty has been removed by the dis- 
covery and improvement of the physical exploration of the chest. Physical 
signs in conjunction with symptoms, render the diagnosis of pulmonary tuber- 
culosis positive in the vast majority of cases. I shall include in this collec- 
tion only cases in which the diagnosis rests on the conjoined evidence of signs 
and symptoms. With some exceptions, the results of exploration of the chest, 
together with the previous history and existing condition of the patient, were 
noted prior to the arrest of the disease. In a few instances, however, the 
cases came under observation subsequently to the arrest, and the diagnosis 
was made retrospectively; that is, the physical signs and the previous history 
were deemed sufficient to render it positive that the patient had been affected 
with tuberculosis. 

Case I. — Abundant Tuberculous Deposit; Arrest and Recovery ; Exa- 
mination Jive and a half yea.rs after the case came first under observation. — ■ 
Ellen Thornbury, unmarried, aged 19 years, came under observation first in 
Dec, 1850. Not aware of any hereditary predisposition to phthisis in her 
family. Was attacked about two years previous with haemoptysis, not pro- 
fuse. Slightly bloody expectoration continued for three weeks. Was in her 
habitual good health up to four or five months prior to the haemoptysis, and 
did not consider herself ill at the time this event occurred. Prior to this 
event was less active and buoyant than usual, but does not recollect that she 
had cough. Had been somewhat hoarse and was conscious of a ticking sound 
in respiration at night. Was always delicate and subject to heavy colds in 
the spring season especially. 

She was engaged in weaving when the haemoptysis occurred, and had worked 
hard. At the moment when she began to spit blood, she was carrying a pail 
of water. Had been engaged in school teaching previous to this attack. She 
kept the bed for three weeks after the haemoptysis, and had for a week stitch 
pains in the side. She does not recollect that she coughed until the following 
spring, when she noticed a cough and a thick yellowish expectoration. Dur- 
ing this spring (1849), she had a second attack of haemoptysis, and six weeks 
afterward, a third. Raised a little blood on the other subsequent occasions, 
and still another recurrence took place in the autumn of 1849. 

She has lost flesh moderately, but does not appear emaciated. Her aspect is 
not morbid. The cheeks present some colour. Has occasionally had chilly 
sensations. The appetite has generally been good. Was subject to diarrhoea 
during the last summer and autumn. For the last two weeks has perspired 
at night. 

She was attended by a botanic practitioner for the eight or nine months 
following the first attack of haemoptysis. In June last she went to a water- 
cure establishment and remained there five weeks. She continued the water 
treatment — the wet sheet, hip-baths, etc. — for three months afterwards. Has 
not worn flannel since leaving the water cure. The' menses have been absent 
since June last. She was regular prior to the first haemoptysis, but irregular 
since that event. 

The pulse is 120, small, vibratory. Respiration 25, and not laboured. 
She experiences want of breath on exercise. 



1858.] 



Flint, Pulmonary Tuberculosis. 



55 



She sits up all day; has lost strength but is not very weak. 

The foregoing account was noted when she came under observation in Dec, 
1850, together with the following physical signs : — 

Dulness in left supra and infra-clavicular regions; equal resonance at the 
base of the chest and laterally on the two sides. Marked dulness over left 
scapula. 

Respiration in front, left side, superior third, feeble, non-vesicular, distantly 
bronchial; right side more evolved and vesicular. Behind, over the left 
scapula, feeble and non-vesicular, expiration prolonged; slight crackling and 
occasional sibilant rale. Less superior-costal movement on left side obvious 
to the eye. The voice slightly bronchophonic at the summit of left side in 
front and behind. 

She left the hospital Jan. 11. 

In Jan., 1852, this patient again came under my observation. She had 
progressively improved in strength during the year that had elapsed, and had 
gained in weight considerably. She presented a healthy aspect. The cough 
and expectoration had steadily diminished, and at this time the matter expec- 
torated was quite small. 

I had prescribed a year previous the cod-liver oil, which she continued to 
take most of time during the intervening period. She had taken in all, three 
gallons of the oil. 

She has been in the country during the past year, occupied in doing house- 
work, and more or less out of doors. She has at no time been confined to 
the bed. 

The appetite and digestion were good. The menses had returned six weeks 
before, and again the day previous to this examination. The pulse was 80 
and the respirations 20 per minute. 

The physical signs were as follows. Summit of left side of chest depressed, 
and expansibility lessened. Respiratory murmur at left summit in front 
feeble, the inspiration shortened, more acute than on the right side, and no 
expiratory sound. Behind in left inter-scapular space and at lower angle of 
scapular, a murmur with both acts of respiration, resembling a friction sound. 
Marked dulness on percussion at the summit of the chest on left side, in front 
and behind. 

This case came next under observation in August, 1855. She applied to 
me at that time for a certificate of sufficient health to warrant her being re- 
ceived as a candidate for admission into the order of the Sisters of Charity. 
She presented a healthy appearance, having considerable colour in the cheeks. 
She had slight cough and expectoration in the morning, and had recently had 
a very slight haemoptysis. 

The physical signs noted at this time were as follows. Upper third of 
chest on the left side, notably depressed. Resonance on percussion notably 
less at the left than at the right summit. The inspiratory sound notably less 
intense at the left summit than at the right, but no marked disparity in pitch 
or quality. On the left side a prolonged sibilant rale in expiration, and 
no expiratory sound appreciable on the right side. Yocal resonance notably 
greater on the left than on the right side. 

I saw the patient again in July, 1856. Her aspect denoted health, and 
she reported well, being free from any symptoms of pulmonary disease. 1 

1 This case is referred to in my work on Physical Exploration and the Diagnosis of 
Diseases Affecting Respiratory Organs, page 508. 



56 



Flint, Pulmonary Tuberculosis. 



[Jan. 



Remarks. — This is one of the most striking of the cases contained in this 
collection. The patient presented evidence of an abundant tuberculous de- 
posit, and at the first examination had well marked tuberculous fever, the 
pulse being 120. Five and a half years afterwards, the pulmonary symptoms 
had nearly disappeared, and she was much disappointed that I did not deem 
her prospect of health sufficiently good for her to undertake the duties of a 
Sister of Charity. A year afterwards, the pulmonary symptoms had entirely 
disappeared, and she reported quite well, the physical signs showing that the 
lungs bad received a certain amount of permanent damage, but not enough to 
compromise health. Although pains were not taken to determine the exist- 
ence of excavations, it can scarcely be doubted that they occurred. Dating 
from the first haemoptysis, the duration of the disease was between seven and 
eight years. The processes of recovery occupied a period of about six years. 

The only medicinal remedy employed in this case was the cod liver oil. A 
considerable change was made in the habits of life. Leaving the duties of a 
school teacher and the subsequent occupation of weaving, she engaged actively 
in housework, and was often in the open air. She persisted in the latter 
duties, and in not considering herself an invalid. No antiphlogistic or debili- 
tating measures were at any time employed. 

This case possesses so much interest that I have given to it greater space 
than I shall generally accord to the cases which will follow. 

Case II. — Small Tuberculous Deposit; Arrest and Recovery. — Dr. M. 
applied to me for an examination of the chest and advice in September, 1851. 
The following account is from the record made at that time. 

He is about 22 years of age. Has recently obtained his medical degree. 
He has applied himself very closely to medical studies, and has also been 
occupied as an operator in a telegraph office. His mother died at 40 years of 
age with what was called quick consumption. He lost a sister 13 years of 
age with some pulmonary affection. His father is living. 

He had slight haemoptysis some time ago ; has looked pallid for some months 
and lost weight. Has not now and has not had cough. Respirations not 
accelerated. 

On bathing day before yesterday had slight recurrence of haemoptysis. He 
noticed that the action of the heart was much increased at the time. 

At the examination the pulse was much accelerated, which may have been 
due, in a great measure, to nervous excitement. Sounds of heart normal. 
Distinct dulness on percussion over left clavicular and infra-clavicular regions, 
and still more marked over the left scapula. No spinal curvature. On aus- 
cultation, slight but distinct crackling in both infra-clavicular regions, during 
the inspiratory act : a species of dry, slowly evolved crepitation. 

I advised him to throw aside his books and go into the country for several 
months, devoting himself to out-door sports. 

Three months afterwards I repeated the examination of the chest. In the 
mean time he had beeu in the country, hunting, fishing, etc. His health had 
become excellent. He had gained obviously in weight. He was adequate to 
perform as much active exertion as most young men of his age. For example, 
he rowed a boat a short time before sixteen miles. He had, however, as he 
thought, contracted a cold three weeks before, and he had some cough and 



1858.] 



Flint, Pulmonary Tuberculosis. 



57 



mucous expectoration. Dulness on percussion in the left infra-clavicular 
region still existed, and over the left scapula. In the left infra-clavicular 
region a crumpling sound as if produced by dry parchment existed both in 
inspiration and expiration, heard during the whole of both acts. The same, 
but less in degree, existed on the right side. 

He had just begun to take cod-liver oil. I advised its continuance, and 
also habits of active exercise. 

The following winter he passed at the south, and very much in the open air. 
He was then appointed assistant surgeon in the army, and has passed the last 
four years on the frontier in Texas, performing oftentimes laborious out-door 
duties. His health has been good. He has been entirely free from symptoms 
of pulmonary disease. I received this statement from him a few days prior 
to the time I am now writing, and his appearance denoted perfect health. 

Remarhs. — The evidence afforded by the symptoms and physical signs of a 
small tuberculous deposit in this case is positive. A speedy arrest followed 
change of habits, exchanging sedentary pursuits for active exercise out of 
doors. The recovery was complete, the patient having now remained well 
for nearly six years. 

Aside from the cod-liver oil, which was continued but for a short time, the 
management consisted in change of habits of life as regards out-door exercise. 

Case III. — Small Tuberculous Deposit; Arrest and Recovery; no 
Management. — Dr. B., of Gowanda, Erie Co., N. Y., requested an examination 
and advice in May, 1853. His age was 28. Mother died of phthisis. Been 
engaged in medical practice three years. 

In October, 1852, after exerting himself in throwing down some bay from 
a scaffold, he had slight haemoptysis. Up to that moment he had supposed 
himself to be in perfect health. No cough or other pulmonary symptoms 
preceded or followed this attack of hemorrhage 

In Jan., 1852, he had a recurrence of the haemoptysis. This occurred while 
he was perfectly quiet, sitting in his office. The hemorrhage was more abund- 
ant than before, amounting to two ounces. No cough or other symptom suc- 
ceeded. More recently two slight attacks of haemoptysis had occurred. He 
notices that he is a little hoarse. Has had slight soreness in the chest, first 
on one side and next on the other. His weight has not diminished since the 
first haemoptysis. The pulse is not and has not been accelerated. The same 
is true of the respirations. 

On examination of the chest, relative dulness exists over the right clavicle, 
and not elsewhere. The respiratory murmur at the left summit is well evolved 
and vesicular, no expiratory sound being appreciable. On the right side it 
is relatively feeble, and a dry, weak crepitation accompanies both inspiration 
and expiration, obscuring the characters belonging to the murmur. Slight 
vocal resonauce at the summit on the right side, and none on the left. 

I advised him to attend to hygiene, and, if symptoms of tubercle should 
become more evident, to change his residence for a southern climate. 

In September, 1854, Dr. B. called upon me and reported himself to be in 
as good health as he had been for several years. He had increased in weight. 
Had had recurrence of the haemoptysis four times, but very slight with one ex- 
ception. Has no habitual cough or expectoration. Has continued to practise 
in Gowanda up to the date of this record, 1st Sept., 1854. On an examination 
of the chest, I found marked dulness over the right clavicle. The respiratory 



58 



Flint, Pulmonary Tuberculosis. 



[Jan. 



murmur at the right summit was feeble and deficient in vesicular quality, 
higher in pitch than on the left side, and a feeble, prolonged expiration was 
appreciable (broncho-vesicular respiration). At left summit the respiratory 
murmur was vesicular, well evolved, and no appreciable expiratory sound. 
No rales on either side. 

Remarks. — The evidence of the physical signs, in conjunction with the 
repeated attacks of haemoptysis, will probably be deemed sufficient to establish 
the presence of a small tuberculous deposit near the apex of the right lung. 
The indications of the tuberculous cachexia, exclusive of the physical signs 
and the haemoptysis, were wanting. The arrest of the disease may be said to 
have been spontaneous. The cachexy was exhausted, as it were, by a small 
exudation, and the latter speedily passed through retrogressive changes, or 
remained quiescent. 

There was, in reality, no management in this case, the patient not only 
refraining from remedies, but not altering materially his habits of life. His 
duties as a practitioner in the country, of course, involved much exercise in 
the open air with considerable exposure. 

Case IV. — Pulmonary Tuberculosis of Twenty-seven Years' Standing ; the 
Disease Non-progressive ; Recovery not taking place. — This case came under 
my notice in March, 1855, at Louisville, Ky. The patient, Mr. 0., was 51 
years of age. His first haemoptysis had occurred twenty-seven years before. 
Prior to that hemorrhage, he had been affected with cough, and had for many 
years been a dyspeptic. He raised at the first hemorrhage about a gill of 
blood. Since then, haemoptysis has recurred about half a dozen times. The 
last attack was during the winter of 1854-5. The hemorrhages have always 
been slight. He had never been free from cough since the first attack of 
haemoptysis. For many years the cough and expectoration had remained 
about stationary. He thinks he expectorates about a gill in twenty-four 
hours. His weight is about 108 pounds, and has varied very little during 
the last twenty years. He weighed 125 pounds before the first hemorrhage. 

He has kept about ever since the first hemorrhage, having been in business, 
successively, as an apothecary, a seller of dry goods, and a wholesale grocer. 
For many years he has only taken some slight palliative remedies, and has 
not had medical advice. 

Both parents were free from pulmonary disease. 

His appetite and digestion have generally been good. 

The chest is considerably distorted. The spine is curved laterally ; the 
sternum at the upper part projects, and the projection extends on either side, 
but most on the right. Percussion sound relatively dull on the right side ; 
the signs obtained by auscultation are not noted. 

Remarks. — Although I have failed to note the physical signs, with the 
exception of dulness on percussion on one side, there can hardly be room for 
doubt that this person was affected with tuberculosis twenty-seven years 
before he came under my notice. It is probable that an arrest of the disease 
had long since taken place, but the pulmonary lesions were of a nature to 
preclude complete recovery. 

This case had never received any medical management. The patient had 



1858.] 



Flint, Pulmonary Tuberculosis. 



59 



taken only some simple palliative remedies, without placing himself under 
the care of a physician. Nor did he at any time materially alter his mode of 
living. His habits were temperate and regular, and he persistingly devoted 
himself to business as far as his strength would permit. At the time of my 
record of the case, and when I last saw him, a year afterwards, he did not 
consider himself an invalid. The arrest of the disease in this instance must 
have been determined mainly by an intrinsic tendency to that result. 

Case V. — Pulmonary Tuberculosis of Eighteen Years' Standing; the 
Disease Non-progressive ; Recovery not taking place— -Between this case and 
the preceding there is a striking coincidence, and it is a curious fact that the 
persons are husband and wife. This case also came under notice in March, 
1855. 

Mrs. 0. was then 45 years of age, and had been married twenty-one years. 
Had never had children. Mother died of apoplexy, and father met with a 
violent death. 

She was attacked with haemoptysis eighteen years before, when she was 27 
years of age. This was three years after marriage, her husband having then 
been tuberculous for several years. Prior to this hemorrhage she had had good 
health, save that she was subject to paroxysms of sick headache. The 
haemoptysis has recurred frequently ever since. She .has averaged eight or 
ten attacks yearly. The quantity of blood lost has generally been small, but 
sometimes copious. She has never been confined to the bed except for a few 
days at a time, when the hemorrhage has been considerable, or when affected 
with either pleurisy or pleuralgia, which for several years recurred every 
winter, lasting for two or three days. For the last seven years she has been 
exempt from the latter attacks. 

Up to four years ago, the menses were regular, but since then they have 
been more or less irregular. 

She has had cough and expectoration ever since the first haemoptysis; none 
before. These symptoms have remained about stationary ; if there is any 
change within the last few years, there has been some improvement. The 
quantity of expectoration daily is about half an ordinary teacupful. It occurs 
mostly in the morning. 

Her weight is within a few pounds of what it was prior to the first hemor- 
rhage. She weighs about 130 pounds. 

Generally the appetite and digestion have been good. 

About twelve years ago she had night- sweats for several weeks. She 
remained within doors all the winter of that year. 

She states that if she is in the habit of going out of doors daily, she feels no 
inconvenience from want of breath ; but after remaining in the house and 
sewing for several days in succession, she lacks breath on taking exercise. 

She has taken very little medicine, following the example of her husband 
in this respect. She has never had medical attendance, except when attacked 
with pleurisy or copious hemorrhage. 

There is lateral curvature of spine in this case. The right side is relatively 
dull on percussion at the summit, in front and behind. Right clavicle 
is projecting; vocal resonance marked at the right summit, and absent at the 
left. Respiratory murmur more evolved on the left side ; sounds and impulse 
of heart normal. 

This patient considered herself in tolerable health, taking charge of a family 
with six boarders. 



60 



Flint, Pulmonary Tuberculosis. 



[Jan. 



Remarks. — The remarks appended to the preceding case are equally applica- 
ble .here. 

Case VI. — Small Tuberculous Deposit; Arrest and Recovery. — A. C., 
aged 19, consulted me, May, 1852, for a cough which had existed for three 
weeks. The cough was at first dry, but had recently been accompanied by 
expectoration of frothy mucus. He had not been as well as usual for some 
time prior to the appearance of the cough, but there had been no definite ail- 
ment. He was serving his time as a printer's apprentice, and for a couple of 
years had worked steadily as a compositor. The pulse was accelerated. Had 
not noticed any want of breath on exercise. 

On examination of the chest, at the summit of the left side, the percussion- 
sound was relatively dull ; the murmur of inspiration more acute, and the 
vocal resonance greater than on the right side. No rales. 

I advised him to quit work, and prescribed for the cough a solution of the 
sulphate of morphia dissolved in the syrup of senega. 

On the 16th of June following, he again consulted me. He had remained 
away from his business for two weeks, and during that time improved rapidly. 
His cough, which had ceased, again returned a few days previous, and he 
complained of a sense of debility. Repeating the examination of the chest, 
I found marked dulness on percussion in the left clavicular and infra-clavi- 
cular regions; the respiration at the summit of the chest on the left side was 
broncho-vesicular with an expiratory sound higher in pitch than the inspira- 
tory. On the right side the respiratory murmur was feeble, vesicular, and no 
sound of expiration. The pulse was 76. Respirations, 28. 

I advised him to give up the occupation of a printer, and to be as much as 
possible in the open air. In addition to the cough mixture mentioned al- 
ready, I prescribed a solution of the citrate of iron and the sulphate of quinia. 

This patient adopted my advice to relinquish the business of a printer, and 
he obtained a situation as salesman in a paper warehouse, where he has since 
remained. The pulmonary symptoms soon disappeared; he regained his 
strength and healthy aspect, and is now in good health. 

A brother of this patient died under my care with phthisis, eighteen 
months prior to the date of the first consultation. 

Remarks. — The history and physical signs sufficed for the diagnosis of a 
small tuberculous deposit. An arrest of the disease followed speedily the 
change from the confinement to the printer's form to an occupation involving 
more exercise both in and out of doors, this change being preceded by a vaca- 
tion devoted to recreation. 

No medical treatment was pursued in this case except the remedy to allay 
cough, and the solution of iron and quinia. 

The recovery has been permanent as well as complete, more than five years 
having elapsed since his restoration to health. 

Case VII. — Small Tuberculous Deposit; Arrest and Recovery. — Mr. N. 
came under my observation while I was engaged in making a series of exami- 
nations of the healthy chest in the winter of 1854-5. He was then attend- 
ing medical lectures at Louisville, and had been a practitioner of medicine for 
four years. Father not living, but did not die with a pulmonary affection. 
Mother still living. His age was 29. 

He enjoyed good health up to about seven years prior to the date of my 



1858.] 



Flint, Pulmonary Tuberculosis. 



Gl 



record, Jan. 1855. He was at that time engaged in school-teaching. After 
continuing this occupation for a year or so, his health suffered. He lost in 
weight; his appetite was impaired, and his muscular strength diminished. 
He had a slight haemoptysis six years prior to the date of my record, not pre- 
ceded or accompanied by cough or any other pulmonary symptoms. Had 
no medical treatment. Took more exercise, but continued school teaching. 
He had a recurrence of the hemorrhage four or six months afterwards, more 
abundant than the first. Still no cough nor other pulmonary symptoms save 
a sense of constriction in the chest. In the mean time, his general health 
had not improved. These attacks were in 1848. He attended medical lec- 
tures at Lexington during the winter of 1849-50. • During this winter he 
had a cough with small mucous expectoration and a sense of constriction felt 
especially in the left side of the chest. After the close of the lectures he had 
a third attack of hsemoptysis, which was quite profuse; he thinks he raised a 
pint of blood- He continued to raise blood for several days after this attack. 

Shortly after this he engaged in medical practice in the country. His 
practice lay in a rough portion of the State of Kentucky, near Frankfort. 
His habits became very active. He continued in active practice up to his 
coining to Louisville to attend lectures in the autumn of 1854. His cough 
ceased soon after he commenced practice. He became strong and vigorous, 
gained in flesh, and had no symptoms of pulmonary disease afterwards. 

He had no medical treatment at any time, except that he took a little ace- 
tate of lead, opium and tannic acid during the last hemorrhage. His aspect 
was perfectly healthy. His weight was about 155 lbs. His habits of living 
were temperate. 

On examination of the chest, the following signs were noted : Chest sym- 
metrical; the superior costal movement on forced breathing somewhat greater 
on the right side; slight but distinct relative dulness at the summit of the 
left side in front, over the scapula behind and in the interscapular space. At 
the base of the chest, behind, the percussion-sound equal on the two sides. 
The respiratory murmur on the left side, at the summit in front, and over the 
scapula, scarcely appreciable on forced breathing, even with Cammann's 
stethoscope. On the right side, tolerably evolved and vesicular. Below the 
scapula the murmurs were evolved and equal on the two sides. Vocal reson- 
ance everywhere more marked on the right side. 

Remarks. — The diagnosis in this instance was retrospective; but taking 
the physical signs in connection with the history, the occurrence of a deposit 
of tubercle six years prior to the examination can hardly be doubted. An 
arrest .of the disease in this instance followed an exchange of the confinement 
within doors, and sedentary habits of school teaching and attending medical 
lectures, for the duties of a medical practitioner in a rough country, requir- 
ing him to be in the open air on horseback much of the time, and involving 
not a little exposure. This constituted the sole management. The recovery 
was in this case complete and permanent. 

Case VIII. — Small Tuberculous Deposit; Arrest and Recovery. — Mr. T., 
of Lewistown, N. Y., consulted me in June, 1848. He was 20 years of age, 
and was pursuing the study of the law. His health had not been good since 
an attack of bilious fever the preceding spring. A dry cough had existed 
for some weeks. He had lost much in weight, and his countenance was pal- 
lid. He was able to be about, although considerably debilitated. Appetite 
No. LXIX.— Jan. 1858. 5 



02 



Flint, Pulmonary Tuberculosis. 



[Jan. 



variable. Complained of no embarrassment of respiration, but panted after 
exercise, and tranquil respiration was hurried, with dilatation of the nostrils. 
The pulse was accelerated, exceeding 100 per minute, and had a vibratory, 
thrilling character. 

On examining the chest, no obvious disparity between the two sides in the 
percussion resonance was found; but in the left infra-clavicular region there 
was a distinct, although slight crepitation at the end of the inspiratory act. 

With the foregoing physical signs, although few, in view of the marked 
symptoms in the case, the patient was regarded as tuberculous. He was ad- 
vised to throw aside his books and live as much as possible in the open air. 
Tonic remedies were prescribed. 

The patient was referred to me by Dr. Eddy, of Lewistown, and nine 
months after the date of the examination, Dr. E. informed me that he had 
completely regained his health, had engaged in business, and gone to Cali- 
fornia. 

Remarks. — The physical sign noted in this case may not seem sufficient 
to establish the correctness of the diagnosis. The evidence is certainly less 
complete than in the great majority of the cases in this collection, but taking 
the facts contained in the history into due consideration, I think that there is 
not much room for doubt. I may remark that this case came under my ob- 
servation more than nine years ago, when I had less confidence in my prac- 
tice of percussion than now, and was not fully aware of the importance of 
carefully percussing over the scapulae. 

The management in this case consisted in changing the habits of a student 
for out-door exercise, and the use of tonic remedies. This case occurred 
before cod-liver oil came into vogue. 1 

Case IX. — Pulmonary Tuberculosis; Arrest of the Disease.— Judge C\, 
aged 37, consulted me in July, 1857. His parents are both living. He 
had seven brothers and two sisters, and has lost a sister and brother by con- 
sumption. 

In 1851, he had cough and expectoration for several months, with loss of 
weight and night-sweats. All these symptoms disappeared on leaving his 
office duties, which had been laborious and confining, and travelling for several 
weeks in the winter season, although much exposed to inclement weather. 
He took no remedies except some simple palliatives of the cough. Last 
winter (1856-7) he had recurrence of cough, and he passed several months 
in South Carolina, taking much out-door exercise. He returned to this city 
much of the way on horseback. He gained in flesh during his southern 
sojourn, exceeding his weight at any previous period of his life. Prior to 
this winter he had for several years been constantly occupied by his judicial 
duties. 

At the time he consulted me, his aspect was healthy; he felt no deficiency 
of breath on exercise; the appetite and digestion were good; the pulse and 
respiration not abnormal, but he had slight cough and expectoration. He 
had slight haemoptysis during the last winter, never before. 

1 Since this article was written, the father of this patient has informed me that he 
is living and well at this time, nine years from the time he came under my obser- 
vation. 



1858.] 



Flint, Pulmonary Tuberculosis. 



63 



On examining the chest there was depression at the right summit, and 
relatively less expansion on forced breathing. Distinct dulness on percussion 
on the right side in .front and behind. No spinal curvature. Respiratory 
murmur at summit of left side well evolved, vesicular, and no sound of expira- 
tion appreciable. On the right side, in front, the inspiration notably more 
acute and less vesicular than on the left, but no expiratory sound appreciable 
(broncho-vesicular respiration). Yocal resonance about equal on the two 
sides. Whispering souffle notably more intense at the left summit. 1 

Behind, over both scapulae, the respiratory murmur feeble, but more evolved 
on the left side. An expiratory sound appreciable on both sides, and higher 
in pitch than the sound of inspiration. 

Remarks. — The evidence from the physical signs of a deposit of tubercle 
at the summit of the right lung, is conclusive ; and, in view of the history, 
it can hardly be doubted that the deposit existed in 1851. His condition of 
late years, and at the present time, shows the disease to have been non-pro- 
gressive. 

In this case no medicinal remedies have ever been employed, excepting some 
simple palliatives for the cough. He tried to take the cod-liver oil, but it 
offended the stomach, and he very soon laid it aside. He pursued this course 
under the advice of my friend and colleague, Prof. Hamilton. He has lived 
generously, taking frequently a little wine or spirit. Although an arrest , of 
the disease has evidently taken place, the recovery cannot be said to be com- 
plete, inasmuch as he still has a little cough and expectoration. He is, more- 
over, stouter, and presents a more healthy aspect than for several years before 
the occurrence of the tuberculous deposit in 1851. 

Case X. — Pulmonary Tuberculosis ; Ancient Pleurisy produced by an 
Injury to Chest; Arrest of the Tuberculous Disease, and Recovery. — R. P., 
aged 31, ship carpenter, formerly seaman, came to me for an examination of 
the chest and advice, September, 1856. 

About four years before, he had received a severe injury at sea on the 
lower part of the right side of the chest. He raised blood the day after re- 
ceiving this injury. He felt pain and weakness in the side for some time, 
but had no medical aid. From the examination of the chest it is probable 
that pleuritis with liquid effusion followed that accident. After this he had 
good health, but two or three times had haemoptysis without cough or any 
other pulmonary symptoms. 

He had never been troubled with cough till two months prior to my exa- 
mination. During this period it had existed constantly, and had progressively 
increased. At first the cough was dry, but he soon began to expectorate, and 
the quantity of expectoration had steadily increased. The matter expecto- 

1 The souffle produced by the act of whispering, or whispering bronchophony, is 
often a valuable sign, to which I have called attention in my vrork on the Diagnosis of 
Diseases Affecting the Respiratory Organs. Since the publication of that work, my 
observations have satisfied, me that this souffle is normally more acute, i. e., higher 
in pitch at the summit cf the left than of the right side, but generally more intense 
on the latter. 1 avail myself of the present opportunity to make this statement, which 
is of practical importance. 



64 



Flint, Pulmonary Tuberculosis. 



[Jan. 



rated was quite consistent. He thought it would amount to a gill in the 
twenty-four hours. 

For five or six weeks he had had diarrhoea daily, but as regards this symp- 
tom he had improved. He had taken several patent medicines for the diar- 
rhoea which had occupied his attention more than the pulmonary symptoms. 
He had had lancinating pains at the summit of the chest, shooting through 
beneath the scapula. These had occurred on both sides, but most on the 
right. He had lost considerably in weight, as he thought about 20 lbs., within 
two months. He had observed some want of breath on exercise. 

He had not given up work except for a few days, and expected to return 
to it the next day. He had sweat at night occasionally. The pulse was not 
accelerated; the respirations 20 per minute, and not labored. 

Physical Signs. — The right side somewhat contracted. The right inter- 
scapular space diminished, but the nipple and shoulder not lowered. The 
right infra-clavicular region depressed and mobility less than on the left side. 
The left scapula more elevated than the right on forced breathing. Dulness 
on percussion marked at the right summit, in front and behind. The whole 
right side relatively dull, but the disparity much greater at the summit than 
below. At the right summit in front and behind, the murmur of inspiration 
almost inappreciable with Cammann's stethoscope, but a prolonged, acute expi- 
ration heard both in front and behind. On the left side a vesicular inspira- 
tion well evolved, with scarcely an appreciable sound of expiration. Yocal 
resonance everywhere more marked on the right side, but the disparity much 
greater at the summit, in front and behind, than below. The whispering 
souffle notably more acute, intense, and nearer the ear on the right than on 
the left side, both in front and behind. 

In view of the signs and symptoms, the diagnosis was tuberculosis of the 
lungs, and the patient was advised to try the cod-liver oil; to live generously, 
taking a little spirit daily, and to continue in his occupation. The patient 
was strictly a temperance man. For the diarrhoea a mixture of the syrup of 
krameria, paregoric elixir, and the chalk mixture, was prescribed. 

October 13th, 1856, this patient reported improvement as regards cough, 
expectoration, and strength. The diarrhoea was promptly relieved. The 
appetite was good. He had not begun to take the cod-liver oil, but promised 
to commence it at once ; nor had he taken spirit as advised. Had kept 
steadily at work since the date of the previous record. 

December 23d, 1856, this patient had gained considerably in weight. He 
presented a ruddy, healthy aspect. He had no habitual cough, and was com- 
petent to do full work as a ship carpenter. His business involved exposure 
as well as severe labour, requiring him to be in the open air, and much of the 
time, as he stated, he worked with his coat off. Excepting some few cays 
occasionally, he considered himself a rugged man. He took the cod-liver oil 
for several weeks, and discontinued it because it appeared to act as a laxative. 

This patient continued to work during the whole winter, remaining in good 
health, and in spring last, emigrated to Kansas. 

Remarks. — A deposit of tubercle in this case occurred during the summer 
season, and the arrest took place in the following autumn, the patient pur- 
suing, unremittingly, the business of a ship carpenter, working laboriously in 
the open air, in all kinds of weather, and much of the time in his shirt 
sleeves. 

The only remedy prescribed was the cod-liver oil, which he began to take 



1858.] 



Flint, Pulmonary Tuberculosis. 



G5 



after an improvement bad commenced and continued for a few weeks only. 
He took spirit for some time sparingly, to which he had previously been un- 
accustomed. 

Case XI. — Small Tuberculous Deposit; speedy Arrest and Recovery. — 
Mr. D., aged 22, clerk in a clothing store, was examined by me, August, 
1856. Two months prior to this date he had a cough for several days, which 
ceased entirely, and he regarded himself well until a week before the exami- 
nation, when he had an attack of haemoptysis. The hemorrhage recurred for 
three successive nights, and then ceased, but he continued to expectorate for 
several days bloody mucus. He had considerable cough in the morning with 
small expectoration. His aspect was not morbid. He was not aware of 
having lost in weight. The appetite was poor. 

Both parents are dead. The father died many years ago, he did not know 
with what disease. The mother died of cholera. The pulse was 80, some- 
what vibratory, compressible. The respirations 20. 

Physical Signs. — No spinal curvature. Very distinct dulness on percus- 
sion at the summit of the right side in front and over the scapula. Equal 
resonance below the scapula on the two sides. Respiratory murmur on the 
right side, in front and behind, relatively feeble, the inspiratory sound deferred, 
and no appreciable sound of expiration. A subcrepitant rale at the summit, 
in front, on the right side. Vocal resonance greater on the right side. Less 
superior costal movement, on forced breathing, on the right than on the left 
side. 

I advised this patient to exercise in the open air as much as possible, and 
on the approach of cold weather to change his residence to a milder climate. 
The latter advice he did not adopt. I prescribed no medicine. 

October 28, 1856, this patient reported quite well. He was entirely free 
from cough. His aspect was healthy, and he had gained in weight. 

May 6, 1857, the patient reported the same. He was entirely free from 
any symptoms of pulmonary disease and appeared quite well. 

Remarhs. — A speedy arrest of the disease took place in this instance. He 
took no remedies. The recovery, for the present, appears to be complete. 

Case XII. — Small Tuberculous Deposit ; Coexisting Emphysema, ; the 
Tuberculous Disease Non-progressive. — Mr. R. came to me to examine the 
chest, August, 1856. I had made two previous examinations, the first time 
five years previous, and the second time a year before. I failed to make 
notes of these two former examinations. He stated that on the first exami- 
nation I found no signs of disease, but on the second I told him that there 
was a small tuberculous deposit at the summit of the left lung. He had had 
haemoptysis shortly before the last examination. He is an intelligent man, 
and his recollection of my statements of the results of these examinations is 
doubtless reliable. After the last examination I prescribed a preparation of. 
iron, but he did not take it, and had had no medical treatment in the mean 
time. His age was about 25. His business, forwarding agent, required him 
to be actively employed in the open air; he was accustomed to live freely and 
recklessly, indulging occasionally in debaucheries. 

Since the last examination he had had more or less cough and moderate 
expectoration in the morning. At times, he was obliged to cough repeatedly 
and with some violence before expectorating, but at other times the expecto- 
ration was easy. He was short-winded on exercise. 



G6 



Flint, Pulmonary Tuberculous. 



[Jan. 



Physical Signs. — Clear percussion resonance on both sides in front, but on 
the left side vesiculo-tympauitic in quality. Behind, relative dulness over 
the right scapula. Resonance clear and equal below the scapulae. On the 
left side the supra and infra-clavicular regions are fuller than on the right 
side. The superior costal movement slight on both sides even on forced 
breathing, but somewhat greater on the right side. No rales anywhere. 
The respiratory murmur well evolved at the right summit in front, and rela- 
tively quite feeble at the left summit. A feeble, prolonged acute expiratory 
sound on the left side. Yocal resonance slightly greater on the left side. 
The whispering souffle distinctly more intense and acute on the left side. 

Over the scapula the respiratory sound almost dull on the left side; feeble 
on the right side, with a prolonged, acute sound of expiration. Vocal reson- 
ance and whisper almost null on the left side, and well marked on the right 
side. 

The condition of this patient since the last examination I have not learned. 

Remarks. — The foregoing physical signs, taken in connection with the his- 
tory, are considered as showing the presence of a tuberculous deposit, coexist- 
ing with emphysema of the upper lobe of the left lung. It is assumed 
that the physical evidence existed a year before; viz., at the second exa- 
mination. The condition of the patient at the last examination showed the 
tuberculous affection to be at least stationary. Excepting slight cough and 
expectoration, the patient was in good health and actively engaged in busi- 
ness. 

The arrest of the disease in this instance took place without any influence 
from management. The patient took no remedies and made no change in 
his habits of life, continuing in active out-door business and given to dissi- 
pation. 

Case XIII. — Pulmonary Tuberculosis ; Arrest of the Disease, and Appa- 
rent Recovery. — J. H. T., aged 24, printer, consulted me Nov. 15th, 1856. 

In the spring of 1854 the lymphatic glands of the neck became swelled, 
and slowly suppurated. The neck was covered with cicatrices presenting the 
characters of scrofula, and occasionally there was still a little discharge. Prior 
to 1854, always had good health; no scrofula in early life. Parents free 
from tuberculous disease. 

In the spring of 1855 he was suddenly attacked with haemoptysis, without 
any obvious exciting cause. Prior to this event he had had no cough or 
other evidence of the pulmonary disease. Cough and some expectoration 
followed, and he had frequent repetitions of haemoptysis during the summer 
of 1855. In the latter part of this summer he consulted S. S. Fitch, of 
New York, who gave him medicines of a tonic nature ; advised him not to 
wear flannel ; to go out as much as possible without an overcoat, and to be in 
the open air a good portion of the time. He took the remedies during the 
following autumn and winter, and followed these directions as regards dress 
and regimen. He passed the winter on a farm in the country. He discon- 
tinued for several months the use of tobacco by direction of Dr. Fitch. His 
health constantly improved. He had no more haemoptysis. Cough and ex- 
pectoration gradually ceased, and he regained his usual Weight. During the 
previous summer he had fallen in weight from 160 lbs. to 130 lbs. 

The summer of 1856 he passed in this city, and was occupied in business 



1858.] 



Flint, Pulmonary Tuberculosis. 



67 



out of doors, viz., obtaining subscribers, etc., for a daily paper. He resumed 
the use of tobacco moderately. Was accustomed to drink beer daily, and 
about once a month he drank to excess — going on a spree with companions 
of the same kidney. His health was good during the summer and autumn. 
Had no cough or any pulmonary symptoms prior to the day on which he 
consulted me. On that day, while walking rapidly, he swallowed a little 
tobacco juice, and immediately raised a single mouthful of blood. This cir- 
cumstance led him to call upon me. Respiration was not laboured or accele- 
rated. Pulse normal. Aspect healthy. Considerable embonpoint. 

Physical Signs. — The chest on both sides apparently flattened ; the antero- 
posterior diameter notably small contrasted with the width. The left side at 
the summit, compared with the right, depressed; the clavicle more projecting. 
Superior costal movement on forced breathing greater on the right than on 
the left side. 

Dulness on percussion marked in front, at summit, and above the spinous 
ridge over the scapula on the left side. Clear and equal resonance on the 
two sides below the scapula. Respiratory sound at the summit in front on 
the left side less intense than on the right side; the inspiration less vesicular, 
and higher in pitch, shorter and followed by a short, acute expiratory sound 
(broncho-vesicular respiration). Over the left scapula the respiratory mur- 
mur more feeble and less vesicular than on the right side. Vocal resonance 
more marked on the right side in front and behind. The whispering souffle 
more acute in front on the left side. 

Remarks. — These physical signs, taken in connection with the history, are 
attributable to a tuberculous deposit which took place during the summer of 
1855. An arrest of the tuberculous disease followed giving up the occupa- 
tion of a printer, living on a farm and much of the time in the open air, 
together with the use of tonic medicines. Excepting the raising of a single 
mouthful of blood during an act of retching, the recovery appeared to be 
complete. 

Case XIV. — Pulmonary Tuberculosis; Excavations; Fistula in Ano ; 
Non-progress of the Disease. — H. F. L., aged 35, accountant, was examined, 
August, 1855. Both parents died of consumption. Of eleven brothers and 
sisters, all but four have died with the same disease. 

When eleven years old he had some chronic affection of the knee, which 
was called "white swelling," and was laid up for a year. After this, prior 
to 15 years before the date of the examination, he had good health. At 
that time he had haemoptysis at night after returning to bed. No cough fol- 
lowed, and he kept about his business as usual. 

Ten years previous to the date of the examination, after great fatigue and 
anxiety incident to the illness and death of a child, he was attacked with a 
fever, and was ill two months. He had no symptoms of pulmonary disease 
at that time, nor between this event and the haemoptysis five years before. 
During convalescence from this fever he contracted a cold, as he stated, and 
had inflammation of the lungs. After recovering from the latter he went to 
the south and remained eleven months. 

Four years prior to the date of the examination he had haemoptysis several 
times, unattended by cough or reduction in weight, and he kept about his 
business as usual. 

During the autumn and winter of 1855, he had cough which progressively 



68 



Flint, Pulmonary Tuberculosis. 



[Jan. 



increased. The cough was at first dry, but expectoration after a time occurred 
and became considerable in amount. He had frequently lancinating pains 
shooting under the right scapula. Feels want of breath on exercise, especially 
on mounting stairs. He lost in weight in the autumn and early part of 
winter, but afterward gained, and at the time of the examination was heavier 
than four years before. 

A fistula in ano had existed for five years, discharging daily more or less 
and occasionally fecal matter. 

Respirations 24, not laboured. Pulse 72. 

Accustomed to take from 4 to 6 glasses of brandy daily for the past six 
years. 

Physical Signs. — Dulness on right side at summit in front and behind. 
Respiratory sound broncho-cavernous on that side. 1 

August 25, 1855. This patient during the summer had good health; 
was engaged actively in business, and took no remedies. He had gained in 
weight, and his aspect was quite healthy. The fistula was his chief source of 
trouble. 

Nov. 14th, 1856. Patient reported as well as on the date of the last 
record. 

Remarks. — It is difficult to fix the commencement of the tuberculous dis- 
ease in this case. The history shows its existence most unequivocally in the 
autumn and winter of 1855. That a deposit had taken place years before is 
probable. The disease advanced to the formation of excavations, and ceased 
to be progressive at that stage. 

There was in reality no management in this case. The patient took a few 
doses of cod-liver oil, and then discontinued this remedy. He continued 
steadily in business, and was much of the time out of doors. He indulged 
moderately in drinking and lived freely. 2 

Case XV. — Pulmonary Tuberculosis remaining Non-progressive for many 
Years; Coexistence of Heart Disease, the latter proving fatal. — C. A., aged 
about 40, tobacconist, was examined by me in consultation with my friend 
and colleague, Prof. White, Dec, 1848. Mr. A. had been in infirm health 
for several years, but had kept steadily engaged in business. He had for 
some years suffered from palpitations and dyspnoea on exercise. Had lost of 
late, in weight, 20 lbs. He had had slight cough and expectoration for 
ten years. 

Physical Signs. — Marked depression at summit of the left side of the chest. 
Dulness at that summit in front and behind, and the respiratory sound bron- 
cho-vesicular. Sounds of heart pure but feeble. A diffused, feeble impulse 
in the praecordia. 

The diagnosis at that examination was, pulmonary tuberculosis, progressing 
slowly j enlargement of the heart by dilatation, without the evidence of 
valvular lesions. 

1 The characters of respiratory sound are described in the record with minute 
details, which are omitted here. 

2 Since this was written, I have met this patient and find that during the present 
summer his health has deteriorated. The pulmonary symptoms denote now pro- 
gressive tuberculous disease, and he has tuberculous laryngitis. 



1858.] 



Flint, Pulmonary Tuberculosis. 



09 



This patient was under my care for a short time in Feb. 1853. He had 
then considerable oedema of the lower extremities, with ascites, and he suffered 
much from palpitation and dyspnoea. The area of dulness on percussion in 
the praecordia was increased ; the impulse feeble and diffused, and the action 
of the organ very irregular ; but no bellows murmur discoverable. The heart 
affection was the most prominent. He had never been entirely free from 
cough and expectoration, which still continued about as for many years past. 
Since the former examination, he had kept steadily occupied in his business, 
and during the preceding five years had accumulated a comfortable property. 

He died in 1855, evidently of the affection of the heart. 

Remarks. — In this case the existence of a tuberculous deposit was deter- 
mined seven years before death, and undoubtedly had already existed many 
years. The coexistence of disease of heart is an interesting feature of the 
case. This disease steadily increased, while the tuberculous affection, as 
judged by the symptoms, remained nearly or quite stationary. The manage- 
ment had reference mainly to the cardiac trouble. The patient was a man 
of great energy of character, and persisted in keeping about and attending to 
his business nearly to the close of life. According to the views of Rokitansky, 
disease of heart antagonizes a tendency to tuberculous deposit, and it may be 
supposed that in this instance the tuberculous disease was retarded or rendered 
stationary by the cardiac affection. Certainly diseases of the heart and pul- 
monary tuberculosis are rarely found associated. 

Case XVI. — Deposit of Tubercles; Expectoration of Calculi; Complete and 
Permanent Recovery . — S., farmer, from Illinois, aged about 40, consulted me, 
June, 1843. For some months prior to January of that year, he had a slight 
hacking cough. During the month of January he had, as he thought, some 
acute pulmonary affection, the symptoms of which are not noted. Subsequently 
he began to expectorate calcareous concretions, and had continued to do so, after 
successive intervals of a few weeks. He brought with him about twenty of 
these calculi, of about the size of small peas, round and solid. They were 
truly calculi, not concretions from the pharyngeal follicles which I have 
known to be mistaken for pulmonary calculi. Those showed me were but a 
small portion of the whole number which he had expectorated. He had 
supplied different physicians with specimens, and not taken pains to procure 
all that had been expectorated. 

Before discharging these calculi, the cough was violent; and after their 
discharge, the expectoration was tinged with blood. In the intervals, his 
cough was slight with very small expectoration. 

During the month of January and before, he lost in weight and strength. 

After that month he had improved in these respects, and when I saw him 
in June, he presented a healthy aspect. 

On examination of the chest, no physical signs of disease were discovered. 
At that time, however, my experience in exploring the chest had been small, 
compared with that of a more recent date. 

In July, 1856, this person called upon me to report the condition of his 
health. He had for many years enjoyed perfect health. After consulting 
me thirteen years before, he continued for some time to expectorate calculi 
occasionally, until, at length, all pulmonary symptoms ceased. Shortly after 
consulting me he had given up severe labour on a farm, purchased land in 



70 



Flint, Pulmonary Tuberculosis. [Jan. 



Iowa, and had become quite wealthy. It appeared from his statement that I 
had encouraged him with a favourable prognosis, and he called to tell me that 
my prediction had been verified. 

Remarks. — Regarding the calculi expectorated as produced by the crete- 
faction of tubercles, this case is an instance of arrest of tuberculosis and re- 
covery, the latter being complete and permanent. There was no medicinal 
management in this case. The patient, prior to the development of pulmonary 
disease, had worked very hard on his farm. He left home for several weeks, 
and afterward relinquished severe labour, but engaged in business which 
required exercise in the open air, buying and selling new lands. 

Case XVII.-— Abundant Tuberculous Deposit; Formation of Large 
Cavity; Arrest of the Disease, and Recovery nearly complete. — Mrs. V., 
German, aged 27, was admitted into hospital, Oct. 19th, 1848. She had 
been ill twenty weeks. Stated that she took cold during her menstrual period 
and was at once obliged to take to the bed. Prior to this she had good health. 
During the attack just mentioned, she had considerable pain in the right side 
and embarrassment of breathing. Some days after the attack she began to 
cough and had free expectoration. She was confined to the bed for six weeks, 
and afterwards had kept the bed a portion of the day, attempting to work the 
remainder of the time. 

At the time of her admission she had copious puruloid expectoration, the 
sputa sometimes partially sanguinolent; respirations 44 per minute; pulse 
104. There was moderate dulness at the summit of the right side of the 
chest ; less superior costal movement on this side ; respiration bronchial. 

The expectoration continued for some time abundant and occasionally tinged 
with blood. After the lapse of a month, however, the quantity was greatly 
diminished, and the condition of the patient in all respects was much improved. 
In a little less than two months she thought herself sufficiently well to resume 
her household duties, and left the hospital. The treatment consisted of pallia- 
tives for the cough; an occasional laxative; the sulphate of quinia and iron, 
and full diet. 

The patient re-entered the hospital March 9th, 1849. The general aspect 
was about the same as when she left the hospital 2 J months before. Cough 
and expectoration continued. Pulse 100. Appetite good. The chest on 
the right side at the summit was dull on percussion, and the respiration 
bronchial. The day following, haemoptysis occurred and was pretty profuse. 

May 14th, it is noted that the expectoration continued to be copious; some- 
times bloody and generally fetid; the countenance not presenting marked 
emaciation. The cheeks constantly red. The extremities of the fingers pre- 
senting bulbous enlargement quite marked with incurvation of the nails. 
Pulse 100. Profuse perspiration at night. Marked dulness on percussion 
over upper part of right side of the chest. Well marked cavernous respira- 
tion over a space about two inches in diameter. Slight depression over this 
space, and pectoriloquy. 

May 31. Copious haemoptysis occurred. 

July 13. It is noted that the patient had daily improved in aspect and 
strength; the cough and expectoration greatly diminished; she was able to 
be up and about, and expected soon to be able to leave the hospital. 

The treatment, as before, consisted of quinia and iron, palliatives and 
generous diet. 



1858.] 



Flint, Pulmonary Tuberculosis. 



71 



Sept. 1851. Under this date I find the following note. This patient shortly 
afterwards left the hospital. A year afterwards I examined the chest cursorily 
and found the signs of an excavation still present, but less marked. She 
had still some cough, but presented a healthy appearance, and considered herself 
quite well; and she had during the year given birth to a living child. 

A year or more after the date of the foregoing note I learned that this 
woman had died ; under what circumstances I could not learn. 

Remarks. — In this case there existed an abundant deposit of tubercle, and 
the disease advanced to the formation of an excavation of large size. Never- 
theless, an arrest of the progress of the disease took place, and considerable 
advance was made towards recovery. The patient was nearly free from pul- 
monary symptoms j regained her flesh and strength ; was able to discharge 
laborious household duties; became pregnant and was delivered of a healthy 
child. Whether she subsequently died from a return of the tuberculous disease 
or some other affection, I could not learn. 

The management in this case consisted in the employment of tonic remedies, 
chiefly quinia and iron; generous diet; exercise in household duties as soon 
as her strength permitted. 

Case XVIII. — Pulmonary Tuberculosis; the Disease Stationary or Pro- 
gressing imperceptibly without Management ; the Patient, a day labourer, 
continuing at work. — B. D., labourer, aged about 30, was admitted into 
hospital Dec. 6, 1856. He presented the following physical signs. Slight 
lateral curvature of the spine, causing some depression of the right shoulder. 
The left side at the summit is depressed; the clavicle more projecting than 
on the right side. Superior costal movement notably greater on the right 
than on the left side. Elevation of right scapula on forced breathing greater 
than of the left. Percussion resonance at the summit on the left side in front 
notably tympanitic; non-tympanitic at the base. Marked dulness over the 
left scapula. Resonance in axillary region and behind below the scapula 
equal on the two sides. At the left summit, in front, no respiratory murmur 
appreciable except at the acromial extremity, where it was broncho-vesicular, 
the expiratory sound prolonged, more intense than the sound of inspiration 
and higher in pitch. Over the left scapula respiration well evolved below the 
ridge and broncho-vesicular. On the right side, at the summit, respiratory 
murmur well evolved and vesicular. Yocal resonance in front notably greater 
on the right side ; almost null on the left side. No whispering souffle on left 
side in front, but well marked on the right side. Over the scapula the vocal 
resonance about equal, but the voice bronchophonic, i. e. near the ear, on the 
left side. Sense of resistance on pressure greater on the left side at the sum- 
mit. Below the scapulae the respiratory murmur well evolved and equal on the 
two sides, or nearly so. Sounds and impulse of heart normal. 

The patient stated that he had had cough for about two years. He began 
to cough in Jan., 1855, and the cough persisted till the following May. He 
had frequent lancinating pains at the summit of the left side. He had con- 
siderable expectoration, and several times raised blood. At no time had he 
been confined to the bed. Kept at work all that time, but frequently lost days. 
Was not aware of losing in weight. 

From May, 1855, to February, 1856, was free from cough. Had good 



72 



Flint, Pulmonary Tuberculosis. 



[Jan. 



health, and worked steadily. Cough began to be again troublesome in July, 
1856. In March and April he was occasionally obliged to keep in bed. 
Continued to labour during the following summer, but was often obliged to 
quit for a few days. Kept at work till the week before he entered the hospital. 

Had never had any medical attendance. G-ot a blister and applied it to the 
chest in the spring of 1855, and in May, 1856, got bled. Drinks whiskey, 
but not to excess. 

His aspect was not morbid. He was not emaciated. He stated that he was 
abundantly strong for work except that his health was somewhat deficient, and 
he was liable to pain at the summit of the left side of the chest. The pro- 
labia were of good colour, and the cheeks ruddy. Respiration 20, and pulse 
84. Had some cough and expectoration chiefly in the morning. 

He remained in hospital about a week, and during this time took cod-liver 
oil and had full diet. The cough and expectoration were relieved, and he left 
feeling able to return to work. 

Remarks. — This case illustrates either the non-progression or extremely slow 
progress of tuberculous disease in an Irish day labourer, without management, 
the patient (excepting now and then, for a day or two at a time) keeping steadily 
at work, living like other labourers of his class, exposed to the same hard- 
ships, and drinking in moderation. 

Case XIX. — Small Deposit of Tubercle; Arrest of the Disease. — Dr. C. 
A. B., aged about 28, in the spring of 1855, had profuse haemoptysis. Prior 
to this event, for some time his general health had not been good, and he had 
had a dry cough. His weight had diminished, and his aspect was morbid. 
He sailed for Liverpool, and after his arrival in England, at London, he had 
another haemoptysis, also rather profuse, continuing for several days. He 
remained in England two or three months, running about, not pursuing any 
medical treatment, living freely, and returned in an emigrant vessel, having a 
protracted voyage. He had recruited very much before sailing for America, 
so that he performed the duties of surgeon to the ship. He continued to im- 
prove on the voyage, and was quite well on his return. Very slight cough 
and respiration, however, continued. 

During the winter of 1855-6, and the summer of 1856, ho continued well, 
doing very little in the way either of practice or study, and living rather 
freely. During the winter of 1856-7, he was engaged in teaching anatomy, 
and was most of his time in the dissecting-room. His general health evidently 
failed in some measure; he lost in weight, and his aspect was pallid. In 
April, 1857, he had an attack of pneumonia, affecting the lower lobe of the 
left lung. He recovered from this attack rather slowly; but after recovering 
from it, his general health improved; he gained in weight, his aspect became 
healthy. He had still a little cough and expectoration. No want of breath 
on exercise. Pulse not accelerated. Appetite and digestion excellent. 

On examining the chest, July 23, 1857, the following signs were noted: 
Well marked dulness at the left summit in front and behind. No spinal 
curvature. Slight depression in front at the left summit. The respiratory 
murmur at the left summit, compared with the right side, deficient, but no 
disparity in pitch or quality apparent. Over the left scapula below the spin- 
ous ridge, a well marked, prolonged, acute sound of expiration. Above the 
ridge a click heard occasionally in inspiration. V ocal resonance everywhere 
greater on the right side. 



1858.] 



Flint, Pulmonary Tuberculosis. 



73 



Remarks — There can hardly be a doubt that there has been a tuberculous 
deposit near the apex of the left lung. The physical signs, in connection 
with the history, warrant not only this conclusion, but that the deposit is not 
recent. It occurred, probably, in 1855, and, in the mean time, the disease 
has undergone arrest. Inasmuch, however, as there still remains slight 
cough and expectoration, the recovery cannot be said to be complete. 

This case cannot be said to have had any medicinal management. The 
arrest followed the voyages across the Atlantic, and a sojourn of two or three 
months in England, with free living. 

Case XX. — Small Tuberculous Deposit; Armrest and permanent Recovery. 
— Dr. W., aged about 35, in 1844 suffered for several consecutive months from 
cough, with moderate expectoration. Haemoptysis occurred during this period 
once. He gradually recovered without medicinal treatment, and with the 
exception of a cough which lasted for two months in 1849, he has enjoyed 
good health, being entirely free from any symptoms of pulmonary disease. 

On examination of the chest, in 1852, there was distinct dulness on per- 
cussion at the summit of the chest on the left side, and the respiration in 
this situation broncho-vesicular ; the inspiration less vesicular, and higher in 
pitch than on the right side. Vocal resonance about equal on the two sides. 

Remarhs. — The retrospective diagnosis in this case seems remarkable in 
view of the history and physical signs. The recovery is complete and per- 
manent, thirteen years having elapsed since the deposit of tubercle occurred. 
There was no medicinal management in this case; the arrest taking place as 
a result of self-limitation. He continued without intermission the practice 
of medicine, and in addition resorted to horseback exercise daily, in which he 
persevered for several successive months. 

This case is given in my essay on variations of pitch in percussion and 
respiratory sounds, published in 1852. 

Case XXI. — Pulmonary Tuberculosis ; Arrest of the Disease. — D. B., 
ostler, aged 26, admitted into hospital, Sept., L851. He stated that he had 
had good health up to a few weeks before his admission. Thought he had 
taken cold. Was attacked with cough, which at first was slight, but increased, 
and was soon accompanied by expectoration. The latter has progressively 
increased in quantity. Had lost about fifteen pounds in weight. The pulse 
was 100; respirations, 20. Expectorates from two to four ounces in the 
course of twenty-four hours. Perspires at night. Appetite tolerable. 

On examination of the chest, the superior costal movement on the right 
side was found to be less than on the left; the summit on the right side was 
relatively dull on percussion, especially over the scapula; the respiratory sound 
in that situation broncho-vesicular, aud a sibilant rale observed, limited to 
the summit on the right side. 

The patient was placed on full diet, and cod-liver oil was prescribed in dose 
of half an ounce three times daily. 

Nov. 6, 1851. The patient reported well, feeling abundantly able to leave 
the hospital and resume his occupation. The cough and expectoration had 
ceased. He had gained in weight. Slight depression existed at the summit 
of the right side of the chest. Dulness on percussion remained and dimi- 



74 



Flint, Pulmonary Tuberculosis. 



[Jan. 



nished mobility. Dry crackling was observed, on auscultation, on the infra- 
clavicular regions on this side. 

The management consisted of nutritious diet and cod-liver oil. 

Remarks. — An arrest of the disease in this case took place, but as nothing 
was known of the patient after his leaving the hospital, it cannot be stated 
that the recovery was permanent. 

Case XXII. — Pulmonary Tuberculosis preceded and accompanied by 
Dyspeptic Ailments, the latter persisting after Arrest of the Tuberculous Dis- 
ease. — Rev. Mr. C, aged about 35, consulted me, December, 1851. He had 
been in the ministry 14 years. During this period and longer he had been 
a dyspeptic. Had always been a student with sedentary habits, taking very 
little exercise, and not fond of out-door sports. He complained of a constant 
sense of debility and of becoming very easily fatigued by any exercise. Had 
suffered from chronic pharyngitis, which still continued. He was thin, but 
not greatly emaciated. Had had more or less cough for years with small 
expectoration. The latter symptoms had lately become more prominent. A 
few days previous, slight haemoptysis had occurred. It had occurred once 
previously, several years before. Pulse was 60 per minute; respiration 25. 
Was easily put out of breath on exercise. 

On examining the chest there were found dulness on percussion at the 
summit on the right side without depression; crackling in inspiration and ex- 
piration on both sides, but more marked on the right side in front and behind; 
diminished mobility at the right summit, and the vocal resonance apparently 
increased, the disparity between the two sides being more marked than usual. 

The patient was advised to take the cod-liver oil ; to take a little brandy 
daily; to relinquish his sedentary habits, exercising in the open air and living 
generously. 

July 2d, 1855, I made a brief note of a second examination of the chest. 
The upper part of the right side was somewhat depressed. Dulness on per- 
cussion continued. Respiratory murmur on the left side in front well evolved 
and vesicular; on the right side less vesicular and extremely feeble— the con- 
trast in intensity striking. Behind, no respiratory sound appreciable over 
either scapula save a prolonged sound of expiration over the right. 

During the period (4 i years) that had elapsed the patient had changed his 
habits materially as regards exercise in the open air. lie had rode and walked, 
and at one time was accustomed to saw wood daily for exercise. He had 
passed a winter at the south, but returned with the conviction that he enjoyed 
better health in a northern climate. At one time he adopted a milk and 
farinaceous diet, and thought that this was favourable to his health. 

Two years have elapsed since the date of the last record, and in reply to 
a letter of inquiry addressed to him since I commenced writing this paper, 
he states that he has now no fixed cough ; that he had a slight hemorrhage 
a year ago, but has had none since; that his general health is about the same, 
being troubled still with indigestion and debility. To quote his language, he 
says : "I often feel as if I were a poor miserable wreck of a man, and gene- 
rally endure life rather than enjoy it." Nevertheless, in the same letter he 
states that he has preached regularly for the last ten months, going five miles 
on the cars on Saturday evening and returning on Monday morning, without 
having charge of the congregation during the week. As regards management 
for the last two years, he writes as follows: " Since I saw you I have used up 



1858.] 



Flint, Pulmonary Tuberculosis. 



75 



hydropathy, homoeopathy, and shall I add, allopathy? That would cut me off 
from the benefit of any suggestions which you may make in reply to this. I 
will not say it then, but only say that since returning from the water cure a 

year ago last spring, t have been under the care of Dr. ; have taken 

some aloes, some iron, an occasional blue pill, lager beer to some extent, etc., 
but all does not avail to remove the old malady and give me strength. My 
experiment of 4 J months at a water cure was more than a failure. If I had 
remained there I believe I would have died. I left greatly prostrated." 

It is evident that in this case an arrest of the tuberculous affection has 
taken place, a fact the full force of which the patient cannot appreciate, espe- 
cially so long as he finds his comfort and desire for useful activity compro- 
mised by his dyspeptic ailments. 

Case XXIII. — Pulmonary Tuberculosis, Arrest, Recovery, Return of the 
Disease after Eighteen Years, ending fatally, and Autoptical Appearances. 
— E. H., aged about forty, had an abscess in the perineum which ended in a 
fistula in July, 1845. The gut was divided, and he was nearly but not quite 
cured, a little discharge continuing. He was then, with this exception, ap- 
parently in good health. In April, 1846, he was attacked with haemoptysis 
which continued to recur for several days, and for which he was bled repeat- 
edly and freely. The symptoms and physical signs of tuberculosis were now 
distinctly declared. In addition to repeated venesections, he was treated with 
digitalis and mercurials. The case ended fatally in the June following. 

On examination of the chest, post mortem, the right lung was filled with 
minute deposits of tubercle, and portions presented tubercular infiltration, a 
few small puruloid collections existing near the apex. Disseminated through 
the left lung were great numbers of miliary tubercles. These appearances 
were manifestly due to a recent tuberculous affection. In addition to these 
appearances, at the upper portions of each lung was a solid mass, of an oval 
form, nearly as large as a hen's egg, somewhat larger on the right than on 
the left side. Over these masses the pressure of the lung presented a marked 
depression and a contracted, puckered appearance. On dividing these masses 
they appeared to consist of condensed parenchyma; the colour was reddish; 
they were rather friable, and contained an abundance of minute calcareous 
particles. They were surrounded by a thick: firm cyst, isolating them from 
the surrounding pulmonary structure. 

The following facts relating to the previous history of the patient have an 
important bearing on the explanation of the appearances first described. The 
patient was engaged in the manufacture of burr mill-stones, and had many 
years before worked at this business. While thus employed he became af- 
fected with cough and other symptoms which were thought, at the time, to 
denote pulmonary consumption. In consequence of these symptoms he ceased 
to labour personally in the business, although he continued to carry it on, 
and he devoted himself to the out-door duties connected with it. This was 
18 years prior to his last illness. He speedily recovered his health, and for 
the period just named was free from pulmonary symptoms, and enjoyed ex- 
cellent health. 

Remarks. — In view of the morbid appearances after death, and the ante- 
mortem history, it is assumed that in this case there had been tuberculosis of 
the lungs eighteen years before death, from which the patient had recovered, 
having good health until the return of the disease which proved fatal. 



76 



Flint, Pulmonary Tuberculosis. 



[Jan. 



The arrest of the disease followed a change from confinement within doors 
and the inhalation of stone dust for active out-door occupation. 

Case XXIV. — Small Deposit of Tubercle; Arrest of the Disease and Reco- 
very. — Mrs. R., aged about 22, during the summer of 1853 suffered from 
cough and expectoration, and pains in the chest. She lost in weight; her 
strength was considerably reduced, and she raised repeatedly bloody sputa. 
I failed to make a record of this case, and the facts of the history are stated 
from recollection. An examination of the chest revealed the physical signs 
of a small tuberculous deposit, but I am unable now to describe the signs. 

She passed the winter at the South, and on her journey thither she was 
attacked with haemoptysis, raising from one to two ounces of blood. She 
took quinia and iron, and also for a short time cod-liver oil. The latter remedy 
was discontinued on account of the patient's antipathy to it. Her health 
improved during the winter, and on returning in the spring she was free from 
the symptoms of pulmonary disease. She became pregnant during the follow- 
ing summer, and bore a healthy child, which is still living and well. The 
winter of 1855-6 she passed at the South, and the next winter in this city. 
Her health remained good j she has regained a rosy complexion, and at this 
moment is perfectly well. 1 

. Remarks. — This is the only case in the collection in which the report is 
not made from notes contained in my clinical records. Of the correctness of 
the diagnosis I do not entertain any doubt. The management consisted in 
change of climate, exercise out of doors, tonics, and the use for a short time 
of cod-liver oil. 

The foregoing series embraces the cases that have come under my observa- 
tion, in which, judging from the history, symptoms, and physical signs, the 
existence of pulmonary tuberculosis was unequivocal, and the arrest of the 
disease equally clear. The collection might be enlarged by adopting a some- 
what wider latitude in the admission of cases, including those in which a tem- 
porary arrest took place, and those that have occurred too recently, or re- 
mained under observation for a period too brief to determine as to the reality 
of the apparent arrest. A still wider latitude would admit cases in which the 
progress of the disease was remarkably slow. A comparison of the latter 
cases, as regards the points of agreement in the management, would certainly 
be a legitimate means of developing results in corroboration of the conclusions 
drawn from the analysis of cases of recovery from tuberculosis. My records 
for" the last few years would supply a pretty large number of cases falling 
under these heads. In fact, I am sure that in a great proportion of the cases of 
pulmonary tuberculosis which I have of late observed, the progress of the 
affection has been retarded, taking as a standard of comparison the usual 
course of the disease some years ago. The clinical observer for twenty years 
need not be told that during this period there has been an entire revolution 

1 A slight perineal fistula has occurred in this case, and been somewhat troublesome 
at times for the past year. 



1858.] 



Mint, Pulmonary Tuberculosis. 



77 



in the management of the disease. As regards my own views and practice, 
I am ready to admit that a better knowledge and appreciation of certain 
points of management have led me to expect at least a marked improvement 
in the symptoms of pulmonary tuberculosis, with much more confidence, in 
the majority of instances, than I ventured to entertain until quite lately. 
To these points I shall incidentally refer in the course of the few remarks 
which are to follow. 

The inquiry will naturally arise, what proportion do these instances of 
arrest of the disease bear to the whole number of cases observed during the 
years that these instances were noted. So large a proportion of the cases of 
which I have notes, are incomplete as regards the progress of the disease and 
the result, that I am unable to meet this inquiry. I wish it to be understood 
that the cases in this collection are not reported in order to furnish data for 
determining, statistically, the chances that the disease will be arrested ; still 
less are they reported with a view to illustrate the success of any peculiar 
plan of management. The object, as already stated, aside from the interest 
which may belong to the cases individually, is to institute a comparison as 
regards those circumstances common to more or less of the cases, which, it 
may fairly be supposed, were concerned in bringing about an arrest of the 
disease. 

It will be noticed that in the caption prefixed to the cases, severally, some 
are characterized by the terms "arrest and recovery," and others by simply 
the first of these terms. An arrest of the disease, it is clear, may take place 
without recovery ; in other words, the tuberculous affection may cease to be 
progressive, the processes of restoration never being fully completed. The 
patient who had been attacked twenty-eight years, or the wife eighteen years 
before, for example, were not free from the symptoms of pulmonary disease, 
yet the history and present condition showed that the disease, as regards 
destructive changes, had for a long time remained stationary. The same is 
equally true of other cases in which the date of the tuberculous deposit 
was much less remote. A very marked degree of improvement in the 
local symptoms, conjoined with the recovery of the normal weight and 
strength, after the lapse of several months, suffices to show that the disease 
is arrested; and this conclusion is not disproved by the renewal of the evi- 
dences of the progress of the disease at a future epoch. Recovery from 
the disease can be pronounced only when, in connection with restoration 
of the general health, the local symptoms have entirely disappeared. This 
recovery may be complete, albeit the patient subsequently falls a victim to 
tuberculosis, as in Case No. XXIII., in which a fresh deposit of tubercle took 
place eighteen years after a former exudation. There may be a recovery 
which is not permanent, but not less a recovery on that account. To be per- 
manent, the disease must not return, or, at all events, not for a considerable 
space of time. Of the cases in this collection, in thirteen an arrest of the 
disease was followed by complete recovery; in eleven, the facts show arrest 
No. LXIX.— Jan. 1858. 6 



78 



Flint, Pulmonary Tuberculosis. 



[Jan. 



without furnishing evidence that the processes of restoration were fully com- 
pleted. To what extent, if at all, are those who have recovered from tuber- 
culosis rendered thereby more liable to the disease thereafter, is an interesting 
question which cannot be answered without more data than are as yet availa- 
ble. In Case No. XXIII. , as just stated, recurrence took place after a period 
of eighteen years. In two of the cases, thirteen years have already elapsed 
without any reproduction of the disease, the dates of the recovery in the 
other instances, extending for variable periods between six years and a few 
months. 

In several of the cases the arrest of the disease was evidently due to an 
intrinsic tendency to that result. In other words, the disease ceased to be 
progressive, in consequence of its self-limitation. This is fairly to be inferred 
in those instances in which no appreciable external influences, in the form 
either of medication, diet, or regimen, were brought to bear on the course of 
the disease. Eight of the cases may be embraced in this category, viz., Nos. 
Ill, IV., V., XL, XII., XIV., XVIII., XX. In these cases the patients 
took no remedies of importance j and continued, unchanged, the same habits 
of living as before the development of the disease. Examining these cases, 
severally, there are no apparent circumstances common to them and distin- 
guishing them from the others, to which this inherent tendency to arrest may 
be imputed. In conformity with the current pathological views, we have 
only to say that in these instances the amount of the tuberculous dyscrasia 
was limited, and was exhausted after a certain quantity of exudation had 
taken place. 

The fact of the existence of an intrinsic tendency to arrest in a certain pro- 
portion of the cases of pulmonary tuberculosis, is highly important. It is a 
fact hitherto not sufficiently appreciated j indeed it is but lately that such a 
tendency, in any instance, has been recognized. Two questions suggest 
themselves in this connection. One is, in how large a proportion of the cases 
of pulmonary tuberculosis does this tendency exist? It will be long before 
data sufficient for determining a definite answer to this question will have 
been accumulated. The second question is, in a measure, involved in the 
first. It is this : in a certain proportion of the instances in which an arrest 
of the disease appears to be due to measures of management, is not the result 
rather attributable to an intrinsic tendency ? This question it is of course 
difficult to answer definitively in individual cases. Both these questions, 
however, are equally applicable to other diseases than pulmonary tuberculosis, 
and, with our present knowledge, are alike unanswerable. The truth is, our 
acquaintance with the natural tendency of many diseases unaffected by ex- 
trinsic influences, is extremely limited, and, for obvious reasons, this know- 
ledge is slowly acquired. The importance of this knowledge, as the true 
point of departure for the study of therapeutical agencies, is sufficiently 
apparent. If it be probable, as must be admitted, that the arrest of the 
tuberculous affection is due to its self- limitation in more or less of the cases 



1858.] 



Flint, Pulmonary Tuberculosis. 



79 



in which measures of management are resorted to, is it not also probable that 
the intrinsic tendency to recovery is sometimes thwarted by injurious thera- 
peutical or other means ? We cannot but indulge more than a suspicion that 
this question demands an affirmative answer. Unpleasant as may be the 
reflection, it must not be blinked that the natural tendency of the disease to 
arrest, it is more than probable, was not unfrequently frustrated by the 
measures formerly employed in cases of tuberculosis, consisting of general and 
local depletion, mercurials, emetics, low diet, confinement within doors, &c. 

Of the measures just referred to, in other words, all antiphlogistic and 
debilitating measures, none entered into the treatment of any of the cases in 
this collection. 1 We are not, therefore, called on to inquire as to the influence 
which any such measures may have exerted in contributing to the result. On 
the other hand, we may ask if the fact of their non-employment was not an 
important circumstance as regards the result ? The answer to this question 
is anticipated in the closing sentence of the foregoing paragraph. 

The occurrence of haemoptysis in a large majority of the cases is a point 
worthy of note. It occurred in eighteen of the twenty-four cases. In ten of 
these eighteen cases, it occurred more than once, and in some it occurred 
several times. 

This proportion exceeds that in which hemorrhage may be expected to 
occur in cases of tuberculosis, according to the researches of Louis (57 of 87 
cases), a fact which goes to show that this symptom is not unfavourable as 
regards the possibility of arrest of the disease taking place. The fact accords 
with the conclusion deduced by Prof. Walshe from his researches, viz., that 
the occurrence of hemorrhage does not hasten the progress of the disease, but 
appears to produce an opposite effect. The fact also accords with the infer- 
ence from observations in individual cases in which hemorrhage seems to 
take place in lieu of a fresh tuberculous exudation. 

Comparing, now, the cases in which measures of management were em- 
ployed [i. e., 16 of the 24 cases, excluding the 8 cases in which no measures 
were employed), in nearly all a change was made in the habits of life. This 
change, with a single exception, consisted in all instances in relinquishing, 
partially or entirely, sedentary pursuits, and giving proportionately more time 
to exercise in the open air. The pursuits relinquished were as follows : 
Teaching school and weaving ; printing in two instances ; teaching school and 
attending medical lectures; study of the law; office duties of a lawyer; 
teaching anatomy ; theological studies and writing sermons y medical studies 
and duties of telegraphist; making millstones; domestic seclusion. In the 
excepted case, the patient relinquished severe labour as a farmer, for several 
months of recreation and travel. In five cases, the change in habits consti- 
tuted the sole measures of management. How much importance belongs to 

1 The only exception to this statement is that in one of the cases the patient had 
been bled once before coming under observation. 



80 



Flint, Pulmonary Tuberculosis. 



[Jan. 



the change in these cases ? in other words, in how far was the result due to 
the change, irrespective of the intrinsic tendency of the disease? Here, again, 
I must be content with raising a question without furnishing facts on which 
to base a definite answer. Inasmuch as improvement followed the change, 
and, moreover, in some instances occurred so speedily and in such a marked 
degree that the relation of cause and effect seemed to be striking, a certain 
amount of agency is fairly attributable to this change. It may be remarked 
here that in none of the instances in which arrest of the disease occurred 
without any measures of management, were the pursuits of the patients 
sedentary ; in all the habits of life were more or less active, and generally 
quite so. We are warranted, then, in concluding that out-door occupation is 
conducive to the arrest of pulmonary tuberculosis. 

The exercise in the open air was not generally of the kind which often goes 
by that title, consisting in simply airings by gentle walks or drives ) but it 
consisted in rough occupation, often involving considerable, and sometimes 
great exposure to the vicissitudes of the weather. In three instances it con- 
sisted in the labour of medical practice, which in two of the instances was in 
the country, and in the remaining instance, in addition to visiting patients, 
horseback exercise was taken daily, and persevered in for several months. 
In two instances the patients (females) performed laborious housework. In 
one instance, the in-door avocations of the lawyer, which had been extremely 
arduous, were exchanged for several weeks of constant travel in midwinter, 
during which the pulmonary symptoms ceased. In one case the patient left 
sedentary pursuits which confined him constantly within doors, for hunting, 
fishing, rowing, etc., to which for several weeks he devoted himself entirely. 
A student at law gave up his profession, and, after recruiting by field sports, 
engaged in business and went to California. One patient continued to labour 
out of doors during the autumn and winter, as a ship carpenter. A professor 
of anatomy left the duties of the dissecting room and of medical practice, and, 
crossing the Atlantic, was on foot daily, running about London and its vicinity 
for several months, a haemoptysis occurring during this time, to which he 
gave no heed. A day labourer continued to work, occasionally losing a day 
or two. A printer went to work on a farm, and afterwards engaged in the 
out-door business connected with the circulation of a daily newspaper. A 
clergyman took to riding and walking and sawing wood. These facts go to 
confirm the correctness of the conclusions which practitioners have frequently 
formed from their observations in individual cases, viz., that laborious, fatiguing 
exercise in the open air is best suited to promote the arrest of pulmonary 
tuberculosis. Such exercise is obtained, in some instances, by engaging in 
field sports in which the mind becomes interested, or in travelling ; in other 
instances by a change of occupation by which sedentary pursuits are relin- 
quished for those requiring active, out-door employment, and in other instances 
by a necessity which compels the patient to continue daily physical labour as 



1858.] 



Flint, Pulmonary Tuberculosis. 



81 



long as possible, as a means of support. This necessity, painful as it may 
sometimes seem, may be far less a calamity than it appears. 

Change of climate entered into the management of but few of the cases. 
In two instances only was there a change of climate prior to the evidence of 
an arrest having taken place. In one of these (No. XXIV.) the patient 
passed the winter season in the southern part of our country; in the other 
(No. XIX.) the patient crossed the Atlantic, and returned after sojourning in 
England a few months. In these two cases there is room for the inquiry, 
how far the climatic change contributed to the result — another inquiry which 
is easier raised than answered. In three other cases, the patient passed a 
winter at the South after the arrest had occurred (Nos. II., IX. and XXII.). 
In two of these cases the health improved during the southern residence; in 
the remaining case (No. XXII.) the patient thought the influence was un- 
favourable. During the period that these cases of arrested tuberculosis have 
been collected, not a few of my patients have resorted to change of climate, 
and hence, in the great majority of these instances, the disease has not been 
arrested. So far as my experience goes, then, it fails in furnishing even 
much presumptive evidence in favour of a beneficial influence from change of 
climate. . On this subject I have been led to conclusions to which others have 
also arrived, viz : that climate, in itself, exerts no special agency in determin- 
ing an arrest of tuberculosis; but that it may favour this result indirectly by 
affording better opportunity for exercise in the open air, and furnishing objects 
of interest to the mind which will secure that object. By the remark just 
made, I do not, of course, mean to be understood as saying that tuberculosis 
is as likely to be developed, other things being equal, in one climate as in 
another. I refer to a remedial influence only. Entertaining the view just 
expressed, it has seemed to me far less important to fix upon a situation sup- 
posed to be the most favourable in its climatic aspects to the tuberculous 
patient, than to select a residence where the inducements to active habits of 
exercise are greatest. To place a patient in a group of invalids, in a particu- 
lar spot where he is expected to derive some specific remedial influence from 
the atmosphere, is rarely useful. The ennui incident to such a position, for 
a man of active habits of mind and body is intolerable, and the moral effect 
of his associations is injurious. Patients will do wisely in avoiding the fa- 
vourite places of resort for those affected with the disease, and in choosing 
points where the incitements to, and the resources for physical exertion 
abound. Generally, the objects of change of climate are better secured by 
frequent change of place than by remaining stationary. Travelling in foreign 
countries, even when, so far as climate is concerned, the change is for the 
worse rather than for the better, may be in a high degree useful, because the 
exercise which it invites is not endured as a task, but accepted as a means of 
mental gratification. . 

As regards diet, it is already implied in what has been stated with reference 
to antiphlogistic or debilitating measures, that it was not an object in the 



82 



Flinty Pulmonary Tuberculosis. 



[Jan. 



management of these cases to lower the powers of the system by reducing 
the alimentary supplies either in quantity or quality. On the other hand,. it 
was a prime object in the instances in which treatment was directed, to sus- 
tain and develop these powers by a highly nutritious plan of dietetics. The 
patients were encouraged to live generously, indulging and cultivating an 
appetite for any and all the varied wholesome articles of food, with a full 
proportion of meat. 1 

This statement expresses, in a few words, the dietetic management of cases 
of pulmonary tuberculosis, which, as it seems to me, is alike consonant with 
the teachings of experience, sound pathology, and common sense. 

It is a significant fact, apparent on referring to the cases which I have re- 
ported, that the appetite and digestion were, in general, not greatly impaired. 
Dyspeptic ailments appear to have been prominent in but one instance (No. 
XXII). 2 It accords with the views just expressed to regard an unimpaired 
appetite and digestion as highly favourable for an arrest of the disease. Ob- 
servation undoubtedly shows us instances in which the tuberculosis is pro- 
gressive notwithstanding the ingestion and apparent assimilation of nutritious 
food; but it probably can show few examples of arrest of the disease when, 
either from disinclination or injudicious management, the diet is insufficient 
for the full support of the body, or fails to be appropriated for that end. In 
the single instance in this collection of cases in which dyspeptic ailments were 
prominent, abundant food was taken and digested notwithstanding the act of 
digestion was accompanied by distressing symptoms. 

No part of the management of pulmonary tuberculosis seems to me of 
greater importance than that relating to diet. In fact, whatever efficiency 
belongs to active habits of exercise, it is reasonable to suppose, is in a great 
measure exerted by means of the increased activity of the processes of assi- 
milation thereby induced. Without the latter it is sufficiently clear that the 
powers of the system are lowered in proportion as the materials of the organ- 
ism and the vital force are expended by the exercise of the voluntary organs. 
There is much scope for remark under this head, but my limits will not per- 
mit a more extended discussion of the subject. 

1 Inasmuch as carbonaceous alimentary principles appear to be highly useful in the 
management of tuberculosis, I have been led to think that saccharine substances, 
when well borne, should constitute a good proportion of the diet. Acting on this 
view, I have been accustomed to advise the free use of sugar by tuberculous patients. 
If it be true that persons employed in sugar-houses are less prone than others to this 
disease, it is a more rational supposition, as it seems to me, that the benefit is derived 
from eating the sugar, than that which attributes it to inhaling an atmosphere loaded 
with saccharine matter. The latter hypothesis has been advocated by Dr. Cartwright 
of New Orleans. 

2 Dyspeptic ailments preceded the development of tuberculosis in Case No. IV., and 
continued to some extent afterward. The subsequent remark in reference to No. 
XXII. is equally applicable to that case. 



1858.] 



Flint, Pulmonary Tuberculosis. 



33 



Diffusible stimulants — wine, beer or spirits — entered, more or less, into the 
management of a considerable number of the cases. These were employed 
mainly as subsidiary to alimentation, or, in other words, as contributing to 
render the digestive processes more active and complete. They were given 
for this end in moderate quantities. Within a period too recent to include 
in this collection the cases of apparent arrest that have come under my ob- 
servation, I have been led to take a larger view of the utility of alcoholic 
stimulants in the management of tuberculosis. I have, of late, advised their 
use much more freely than formerly, and I think I cannot be mistaken in 
attributing to them much value. I have observed that patients affected with 
tuberculosis are often able to take spirits in large quantity without experiencing 
stimulant or intoxicating effects. The disease appears to be one of those in 
which these effects are with difficulty produced. I am tempted here to cite 
an instance which came under my notice not long since. I visited, in consulta- 
tion with a professional friend, a patient in an advanced stage of tuberculosis : 
he was scarcely able to sit up ; expectorated puruloid matter in great abund- 
ance; had hectic paroxysms with profuse sweating, and was much emaciated. 
My friend, who had just taken charge of the case, attached great importance 
to the free use of stimulants in this disease, and I was not inclined to interpose 
any restrictions. In a few weeks I learned that the condition of the patient 
was greatly improved; the quantity of expectoration was much diminished; 
the hectic paroxysms were less marked, and he had gained sufficient strength 
to walk about the streets. He had taken daily three quarts of pretty sub- 
stantial stock ale, with about half a pint of brandy! This was conjoined 
with a highly nutritious diet. In this case, although the patient had not been 
addicted to drinking, the very large quantity of stimulants taken daily pro- 
duced no intoxicating effect. In my own practice I have not witnessed so 
striking an illustration as this; but I have repeatedly known stimulants taken 
in quantities which in health could hardly be borne without manifest excite- 
ment and no stimulating effects produced on the circulation and nervous sys- 
tem. The ordinary stimulant effects of fermented and spirituous liquors in 
health I have been led to regard as furnishing a criterion by which to limit 
their use in cases of tuberculosis. If these effects are produced the quantity 
is too large, and any quantity within this limitation will be likely to be useful. 1 

1 With respect to the kind of stimulant best suited to cases of tuberculosis, whether 
beer, wine, or spirit, I have nothing definite to offer as the result of my own observa- 
tions. In some parts of our country it is supposed that the common whiskey of the 
country is much to be preferred. My rule has been to consult the taste and experi- 
ence of the patient. Generally, I think, the choice will be between spirits and beer. 
Individual peculiarities must be taken into account. I had lately a patient who took 
great pains to procure an excellent article of the Bourbon whiskey, but when obtained 
the effect was inferior to the common corn whiskey, and he was obliged to return to 
the latter. The superior virtue supposed to belong to the common whiskey has been 
attributed to the larger quantity of fusel oil which it contains. 



84 



Flint, Pulmonary Tuberculosis. 



[Jan. 



A consideration of great importance is involved in this subject, viz., the lia- 
bility that the patient will acquire habits of intemperance, which would cer- 
tainly render questionable the advantage of an arrest of the disease. Assum- 
ing that this liability is incurred, and, at the same time, that the free use of 
stimulants increases the chances of arrest of the disease, can there be a ques- 
tion as to the duty of the physician to give the patient the benefit of the 
remedy even at a certain amount of risk of his becoming intemperate? If 
this remote effect were not a contingency, but was shown to follow uniformly, 
or even in a large proportion of cases, the question would be different. It 
remains to be ascertained by a collection of facts how great is the liability to 
this result. I have not space, were this a proper occasion, to discuss the 
causation of intemperate habits,- but I will remark, I cannot but entertain 
the hope, if not conviction, that drunkenness is rarely due to the use of 
stimulants strictly as a remedy, divested of social associations, especially 
when they are given under conditions of disease which antagonize the effects 
for which they are taken in health, and when the production of these effects 
is considered as contraindicating or limiting their use. 

It remains to notice the measures more distinctly medicinal which were 
employed in the reported cases. I shall omit ail reference to the various 
palliatives which must play an important part in the treatment of cases of 
tuberculosis as well as other diseases. These details were omitted in the con- 
densed histories of the cases reported. The remarks under this head will 
occupy small space, for it is a striking feature, which the cases present in 
common, that very little medication was resorted to. In no instance were 
any remedies given with reference to a special influence on the tuberculous 
cachexy, unless the cod-liver oil be regarded as a remedy of that kind. To- 
nics frequently entered into the management. These were given with a view 
to their effect on the processes of digestion and assimilation, and their import- 
ance is to be measured by this effect. In so far as they tend to increase the 
activity of these processes, remarks on their value are already anticipated in 
what has been said under the head of dietetic management. I cannot doubt 
that in many cases they form an important part of the treatment. 

The cod-liver oil does not hold a conspicuous place in the management of 
these cases. Several of the eases occurred before this remedy came into 
vogue. In other instances it was not taken, or taken for a short time only, 
in consequence either of a strong repugnance to it on the part of the patient, 
or its being found to disturb the digestive organs. In very few of the cases 
was its use persisted in for a long time. It was continued longest in one of 
the most interesting and striking cases in the collection (Case No. I.). The 
inference which the reader might naturally draw from the histories of these 
cases as regards the writer's opinion of the value of the cod-liver oil, would 
do injustice to this opinion. Had a larger number of these cases occurred 
within a more recent period, or were I to report the cases during the last few 
years in which the progress of the tuberculous affection appeared to be greatly 



1858.] 



Flint, Pulmonary Tuberculosis. 



85 



retarded, although not arrested, this remedy would be found to enter more 
generally and often largely into the treatment. That it is a valuable remedy 
in the management of pulmonary tuberculosis I can scarcely entertain a doubt; 
but it is to be considered that since it has become emphatically the remedy 
employed in this disease, improved pathological views and the lessons of ex- 
perience have wrought a radical change in the management as regards other 
measures — a change consisting in the abandonment, to a great extent, of an- 
tiphlogistic and debilitating measures, and a recognition, more and more, of 
the importance of measures of an opposite character. Consequently, assuming 
(what is undoubtedly true) that the disease is managed more successfully of 
late than a few years ago, it is not easy to determine how much of this greater 
success is to be attributed to the use of the cod-liver oil and how much to the 
change just referred to. Practically, this is an important problem, but data 
sufficient for its solution are not yet available. The facts which I have col- 
lected certainly show that arrest of the disease takes place when it is not due 
to this remedy. 

A point pertaining to the mental constitution of persons affected with 
tuberculosis seems to me worthy of notice. As regards the successful manage- 
ment of the disease, much depends on the patient's energy and perseverance. 
Tuberculous patients, as is well known, usually entertain sanguine expectations 
of recovery; but in a large proportion of cases they expect recovery to take 
place without any extraordinary agency on their part to secure that result. 
The disease, while it engenders hopes which are so often fallacious, seems 
frequently to impair that determination of purpose without which the means 
requisite to effect an arrest will not be efficiently pursued. A passive expect- 
ancy of recovery and a calm acquiescence in the prospect of a fatal termina- 
tion, belong to the natural history of the disease. On referring to the cases 
which I have reported, I find that, in general, the persons manifested greater 
resolution than is usually associated with the tuberculous cachexy. This was 
due in some instances to innate strength of character, and in other instances 
to the force of circumstances. A feeling of inability from his situation to 
give up to the disease may operate in behalf of the interests of the patient 
much more powerfully than the apparent advantage of leisure and wealth. 
I was impressed with the truth of this remark by a conversation since I began 
to write this paper, with a person whose case is included in the foregoing 
report. The person referred to is an esteemed medical friend who was affected 
with tuberculosis thirteen years ago (Case No. XX.). At that time young in 
the profession, and dependent upon it, it seemed to him out of the question 
to relinquish, even temporarily, its duties; and, fully sensible of his danger, 
he deliberately resolved to continue his labours as long as possible, and to die 
in harness should the disease prove fatal. He attended to all his calls, night 
and day, and, in addition, practised daily and systematically the curative mea- 
sure pronounced infallible by the great Sydenham, viz., horseback exercise. 
A person of a character less resolute, or so situated as not to feel the same 



86 



Coolidge, Vital Statistics of War. 



[Jan. 



incentives to exertion, would perhaps have succumbed to the same amount of 
disease. 

In conclusion, the general views which, with our present knowledge, are to 
govern the management of pulmonary tuberculosis may be summed up in a 
few words. The grand ends to be attained are, the removal of the cachexy 
on which the progress of the disease depends; the consequent arrest of the 
disease, and the promotion of the processes of restoration. There is no spe- 
cial medication to be pursued for the attainment of these ends; they are to 
be attained by measures which, in general terms, develop and strengthen the 
powers of the system. This mode of expression, it is true, in a scientific 
point of view must be considered rather vague; but in a practical sense it has 
a meaning sufficiently definite. The measures are hygienic rather than medi- 
cinal; but much importance often belongs to the latter. The hygienic mea- 
sures which are most important are laborious exercise in the open air conjoined 
with agreeable mental occupation, and, as conducive thereto, frequently change 
of business, the selection of a more eligible climate, and travelling are desir- 
able, if not necessary; generous diet, and in many if not most instances, the 
free use of alcoholic stimulants. The medicinal remedies, in addition to those 
which are simply palliative, are chiefly those of the tonic class, and in this 
category may be included the analeptic remedy which has of late years had 
so much celebrity — the oleum jecoris aselli. 

September, 1857. 



Art. III. — The Vital Statistics of" War, as shown by the Official Returns of 
the British Army During the IVar with Russia, and by those of the United 
States Army During the War with Mexico. 11 By Assistant Surgeon 
Richard H. Coolidge, U. S. Army. 

Within the last ten years two memorable wars with their brilliant feats of 
arms, their instances of consummate generalship and of individual heroism, 
have attracted in a pre-eminent degree the attention of the civilized world. 
Is it not the province of the medical profession to examine the official records 
of those wars, to ascertain the amount of sickness and mortality with which 

1 Dispatches and Papers relative to the Campaign in Turkey, Asia Minor, and the 
Crimea, during the War with Russia in 1854-55-56, &c. &c. Compiled and arranged 
by Captain Sayer, Deputy Assistant Adjutant General, Horse Guards. London, 1857. 
(Statistics and returns prepared by authority.) 

Statistical Report on the Sickness and Mortality in the Army of the United States. 
Compiled from the records of the Surgeon General's office, and published by authority 
of the Senate. Washington, 1856. 



1858.] 



Coolidge, Vital Statistics of War. 



87 



they have been attended, and to devise, if possible, some means by which the 
terrible sacrifice of life consequent upon a state of war may be lessened ? 

The war between France, England and Turkey on the one side, and 
Eussia on the other, was distinguished by the greatness of the numerical 
force engaged, and the vast amount of material employed, as well as by the 
science, energy, and perseverance displayed on both sides ; while that of the 
United States and Mexico, though carried on with a less imposing military 
array, was nevertheless characterized by events no less brilliant, and by feats 
of arms exhibiting no less of perseverance, and of military skill. 

The records of military surgery attest that the advance made in military 
science, and the improvement and multiplications of the means of attack and 
of defence, have lessened rather than increased the loss of life arising from 
actual conflicts of arms. It is to be feared, however, that although the pro- 
gress made in medicine and surgery may, and probably has, lessened the 
proportion of deaths to the number of sick and wounded, yet that the loss of 
life from diseases incident to large armies, has not, in the aggregate, been 
diminished. The application of known principles of hygiene to armies and 
navies, has, under ordinary circumstances, been attended with the happiest 
results. Thus, in the British navy, the deaths in " 1779 were 1 in 8 j in 
1811, 1 in 32; and in 1836, 1 in 72." It is, probably, impossible to apply 
those principles, or to enforce prophylactic measures, as generally and as 
rigidly in large armies as in fleets, but surely the sanitary condition of troops 
in the field exhibited in these statistics, not only admits of, but imperatively 
demands correction. 

It is believed that though the circumstances of the respective campaigns in 
which the armies of England and of the United States were engaged, widely 
differ, the statistics of both admit of comparison; and that the general results 
afford material for the serious consideration of all concerned in the formation, 
discipline, and economy of armies, as well as for those immediately connected 
with their hospital service. 

It is evident that in a comparative analysis of statistics not based upon 
precise or uniform data, but relating to dissimilar numbers and covering un- 
equal periods of time, much room is afforded for error, and for so stating the 
results as to make them conform to the opinion of the individual, or, in 
instances like the present, to render them subservient to national prejudice 
or pride. 

The writer has no other object in view than that of presenting the general 
vital statistics of those wars as shown by the official returns j and of exhibit- 
ing in a clear and concise form the magnitude of those evils of war which, in 
his opinion, admit of palliation. 

The material at command is not such as to admit of the consideration of 
the diseases of those armies, or of the special causes which led to them j but 
as the returns embrace the statistics of several kinds of troops engaged in 



88 



Coolidge, Vital Statistics of War. 



[Jan. 



dissimilar operations, the results will, it is believed, give a close approxima- 
tion to the average loss of health and of life incident to a state of war ; and 
will also show the ratio of such loss consequent upon actual conflicts with the 
enemy, to that from diseases following the ordinary exposure and hardships 
of an active campaign. 

In order that these statistics may be understood, and receive their true 
value and nothing more, it is considered advisable to precede them by a sum- 
mary statement of the principal events of the war with Russia, and of that 
with Mexico; to point out the leading circumstances affecting the two armies; 
and to note those things which serve to compensate for the different character 
of their campaigns, and for the disparity in their relative strength. 

The principal events of the war with Russia as connected with the service 
of the British Army, may be summarily stated as follows : The embarkation 
of troops from England commenced on the 22d of February, 1854, and the 
first divisions of the British Army arrived "in the East" in April following. 
The Allied Armies landed in the Crimea, September 14, 1854, and on the 
20th of that month fought the battle of the Alma. The first bombardment 
of Sebastopol commenced on the 17th October, 1854, from which time until 
the final assault and capture of that city, September 8, 1855 — a period of ten 
months and twenty-two days — the allied armies were continually engaged in 
the siege of that place. In addition to the exposure and frequent conflicts 
with the enemy necessarily attendant upon siege operations, those armies 
fought five battles. The battle of Balaklava, October 25, 1854; the battle 
of Inkerman, November 5, 1854 ; the "first general assault" upon Sebasto- 
pol, June 18, 1855 ; the battle of the Tchernaya, August 16, 1855; and the 
final assault upon Sebastopol, September 8, 1855. 

The declaration of peace was announced from the Foreign Office, London, 
March 31, 1856. 

A portion of the " old," or regular army of the United States, which had 
been for some months encamped at Corpus Christi, Texas, advanced on the 
8th of March, 1846, to tjie Rio Grande, opposite the Mexican town, Mata- 
moras. On the 25th of April, a detachment from that army was attacked by 
a large Mexican force. The principal events of the war which immediately 
followed this act of hostility, may be thus enumerated : The battles of Palo 
Alto, and of Resaca de la Palma, May 8th and 9th, 1846 ; siege of Fort 
Brown, May 4th to 9th, 1846 ; battle of Monterey, September 21st, 2 2d, 
and 23d, 1846 ; battle of Buena Yista, February 22d and 23d, 1847 ; siege 
of Vera Cruz, March 9th to 28th, 1847; battle of Cerro Gordo, April 18th 
and 19th, 1847; battles of Contreras and Churubusco, August 19th and 20th, 
1847 ; battle of Molino del Rey, September 8th, 1847 ; battles of Chapulte- 
pec and City of Mexico, September 12th, 13th, and 14th, 1847. 

The President's proclamation declaring the termination of the war, was 
announced in orders from the War Department July 6th, 1848. 



1858.] 



Coolidge, Vital Statistics of War. 



It appears from the preceding statement of facts, that the actual duration 
of the two wars was nearly the same ; and that in both, a period of about 
eighteen months elapsed between the first movement of troops towards their 
respective theatres of war, and the crowning events of those contests, the 
taking of Sebastopol, and the capture of the City of Mexico. 

At the ' commencement of hostilities, the United States Army present at 
the seat of war numbered about 3000, being about one-fifth of the total 
regular (old) force employed during the war. 

At the landing in the Crimea, the number of British troops amounted to 
26,800, being a little more than one-fourth of the aggregate strength of that 
regular army during the war. 

It is probable that with both armies the relative proportion between the 
average numbers actually on duty at the seat of war, to the aggregate force 
employed in each during the whole period of the war, was maintained with 
some degree of uniformity ; but the data to determine this point are wanting. 
In the tables which are herewith presented, the official figures are strictly 
adhered to, the losses per cent, being calculated therefrom. As, however, 
the results of such calculations do not truly represent the relative loss per 
cent, to the actual average number of officers and men in the field, it has been 
assumed in the last table of the series, that the average force constantly in the 
field throughout the war, or for the whole period of service, was one-half 'of the 
aggregate force mustered into service, or employed in the war. As respects 
the British Army, the writer has no positive means for judging whether this 
assumption is a fair one, whether it does or does not approximate the true 
average ; but with regard to the regular (old) army of the United States, and 
to the volunteer force, he believes that it does represent very nearly the true 
average. The "additional force," known as the "ten new regiments/' called 
into service during the war with Mexico, had probably an average of two- 
thirds of their aggregate numbers actually in the field. 

The official returns of the condition of the British troops, from which these 
statistics have been compiled, cover a period of twenty-five months and six 
days, commencing February 22d, 1854, and ending April 1st, 1856. As, 
however, only " the G-uards" and three regiments of infantry had embarked 
from England prior to the 1st of March, the six days in February have been 
neglected in calculating the ratios of losses sustained, and the term of service 
has been stated at twenty -five months. 

The official statistical tables respecting the " old" or regular army of the 
United States, which have been used in this paper, cover a period of twenty- 
six months, from May 1st, 1846, to July 1st, 1848. The statistics of the 
" additional force," or the "ten new regiments," and of the " volunteer force," 
are given separately, both for the reason that their terms of service were 
much less than that of the regular army, and because it is desirable on many 
accounts to compare the results of different organizations. It is to be par- 



90 



Coolidge, Vital Statistics of War. 



[Jan. 



ticularly observed, that the sole object of this paper being to show the effects 
of war upon the health and lives of those engaged therein, the losses set down 
in the official returns of the British Army under the headings " Prisoners of 
"War," and " Desertions/' and in those of the United States Army under 
"Resignations/' "Desertions," and "Discharges by Expiration of Service," 
are not included in the statistical tables which follow. 

Under the "Invalided Home" of the British returns, and the "Discharges 
for Disability and by Order," of the United States returns, are included all 
those who from disease or wounds were rendered non-effective. The persons 
thus discharged from the United States Army, were sent to their homes at 
the public cost, and most of them were pensioned. It is known that the 
mortality in this class was very great, but there are no data by which to ascer- 
tain its actual amount. 

The sufferings of the British Army from the severity of the winter in the 
Crimea, and from cholera, find their counterpart in the exposure of the 
United States Army to the intense heat and fevers of the Bio Grande and of 
Yera Cruz, and in the general prevalence of "Mexican Diarrhoea" which 
proved its severest and most fatal scourge. 

With these preliminary and explanatory remarks the tables are submitted. 



No. I.— Table showing the Aggregate Strength of each Army in Officers and 
Men; the Deaths; and the Numbers rendered Non-effective from all causes. 



Forces. 


Total strength ; 

officers and 
men, including 
reinforcements. 


Deaths from 
all causes at 
the seat of 
■war. 


Invalided home 
(British Army). 
Discharges for dis- 
ability and by order 
(U. S. Army). 


Total loss. 


British Army. 
Regulars 

Laud Transport Corps 
British German Legion . 
British Swiss Legion 


97,864 
7,575 
3,753 
2,121 








Total . 


111,313 


21,097 


16,308 


37,405 


United States Army. 
Regulars 
Additional Force 
Volunteers 

Volunteer General Staff . 


15,736 
11,186 
73,260 
272 








Total . 


100,454 


12,896 


12,252 


25,148 



In the other tables of this series the statistics of the regular troops of the 
British Army will alone be given, as the Land Transit Corps did not arrive at 
the seat of war till the spring of 1855; and the German and Swiss Legions 
not until the fall of 1855. 



1858.] 



Coolidge, Vital Statistics of War. 



91 



No. II. — Table showing the Loss sustained in consequence of Engagements 

with the Enemy. 



Forces. 


Total 
strength 
officers 
and 

men. 


Total 
period 

01 

ser- 
vice. 


KILLED IN BATTLE. 


DIED OF WOUNDS. 


TOTAL KILLED AND 
DIED OF WOUNDS. 


Offi- 
cers. 


Men. 



Total. 



Offi- 
cers. 


Men. 


Total. 


Offi- 
cers. 


Men. 


Total. 




British Army. 




Mos. 




















Regulars . 


97,864 


25 


157 


2598 


2755 


86 


1933 


2019 


243 


4531 


4774 


United States Army. 
























Regulars . 


15,736 


26 


41 


422 


463 


22 


307 


329 


63 


729 


792 


Additional Force 


11,186 


15 


5 


62 


67 


5 


71 


76 


10 


133 


143 


Volunteers 


73,260 


10 1 


46 


467 


513 





100 


100 


46. 


567 


613 



Forces. 



British Army. 
Regulars . 

United States Army. 
Regulars . 
Additional Force 
Volunteers 



LOSS PER CENT. 



Whole 
ser- 
vice. 



4.87 



5.03 
1.27 
0.83 



Month- 
ly ave- 
rage. 



0.19+ 



0.19+ 

0.08 

0.08 



WOUNDED IN BATTLE. 



Offi- 
cers. 



515 



118 

36 
129 



Men. 



11,361 



236 
1,189 



Total. 



11,876 



1,803 
272 
1,318 



Proportion 
of deaths 
to the 
number 

■wounded. 



1 in 5 



1 in 5.48 
1 in 3.58 
linl3.18 



Proportion 
Total | of killed and 
killed [wounded to 

and the total 
wound-! strength, 
ed. officers and 
men. 



14,631 1 in 6.68 



2,266j 1 in 6.94 
339 1 in 33.00 
1,831 1 in 40.01 



Having appended a note to this table, explaining the comparatively small 
loss in battle of the " additional" and volunteer troops, it is proper to direct 
special attention to the comparatively greater losses from ordinary causes 
sustained by those troops, as shown in the following table. It is believed that 
the "additional force" had a greater number of men constantly in the field, 
in proportion to their aggregate strength, than either the regulars or volun- 
teers, and that the volunteers had the smallest number in proportion to their 
aggregate force. The " ratios" in Table III. are therefore too high for the 
" additional force," and too low for the volunteers. 



1 The regiments of volunteers were mustered into service for unequal periods, from 
three to twelve months. The average period of their service is given in this table as 
officially reported by the Adjutant-General of the Army. As nothing is further from 
the intention of the compiler than to lead to erroneous conclusions, the reader is de- 
sired to bear in mind, while examining this table, that the proportion of volunteers 
actually engaged in battle was relatively less than that of either the "additional" or 
regular troops; that their period of service was very much less; and also the fact 
that the "additional force," as well as the larger portion of the volunteers, were not 
brought into service till after many of the battles had been fought. The relative loss 
in battle of these troops was, from these circumstances, of necessity less than that of 
the regular troops. 



92 



Coolidge, Vital Statistics of War. 



[Jan. 



No. III. — Table showing the Number of Deaths from Ordinary or Accidental 
Causes, and the Numbers "Invalided Home," or Discharged for Disability. 





Total 


Period 


ORDINARY AND ACCIDENTAL DEATHS. 


Forces. 


strength, 
officers 
and men. 


of 
ser- 
vice. 






Men. 


Total. 


Loss per cent. 







leers. 


Per month. 


Total. 


British Army. 
Regulars 


97,864 


25 


143 


15,667 " 


15,810 




0.64+ 


16.15 


United States Army. 
Regulars 

Additional Force . 
Volunteers . 


15,786 
11,186 
73,260 


26 
15 
10 


49 
36 
Not stated 




2,713 
2,085 
6,448 


2,762 
2,121 
6,448 




0.67+ 

1 Oft 1 

0.88 


17.55 
18.96 
8.80 




INVALIDED AND DISABLED. 






Total 
loss per 

opr\t 


Loss per 
cent, 
per 


Loss per 
cent, 
per 


Forces. 


Total 


Loss per cent. 




Aggre- 
gate loss 




officers 
and men. 


Per month. 


Total. 










month. 


annnm. 


British Army. 
Regulars 


16,050 


0.65 




16.40 




31,860 


32.55 


1.30 


15.60 


United States Army. 
Regulars 

Additional Force . 
Volunteers . 


2,155 
881 
9,169 


0.53 

0.52+ 

1.25 


13.69 
7.87 
12.51 




4,917 
3,002 
15,617 


31.24 
26.83 
21.31 


1.20 
1.79 
2.13 


14.40 
21.48 
25.56 



Assuming that in the British army, and in the regular and volunteer troops 
of the United States, the average number of officers and men actually engaged 
in the campaigns through the entire period of the war, or of their term of 
service, was one-half of the aggregate number mustered or received into ser- 
vice during the war; and that in the " additional force" this average was two- 
thirds of its aggregate strength (believed to be a near approximation to the 
true average), we have the following results : — 



Forces. 


Term 

of 
ser- 
vice. 

Mos. 


KILLED in battle 

AND DIED OF 
WOUNDS. 


deaths: ordi- 
nary AND ACCI- 
DENTAL. 


INVALIDED 

AND 
DISABLED. 


LOSS PER CENT. 
FROM ALL THESE 
CAUSES. 


Loss per cent. 


Loss per cent. 


Loss per cent. 


Loss per cent. 


Total. 


Annual. 


Total. 


Annual, 


Total. 


Annual. 


Total. 


Annual. 


British Army 


25 


9.75 


4.68 


32.31 


15.48 


32.80 


15.72 


74.86 


35.88 


U. S. Army 


26 


10.06 


4.56 


35.10 


16.20 


27.38 


12.60 


72.54 


33.36 


Additional Force 


15 


1.9] 


1.51 


28.44 


22.68 


15.74 


25.02 


46.09 


49.21 


Volunteers 


10 


1.25 


1.49 


17.60 


21.12 


25.02 


30.02 


48.87 


52.63 



It is possible that the "loss per cent." on the basis assumed in the above 
table may give a higher ratio than the true one. This is more likely to be 
the case with regard to the British army than with that of the United States; 



1858.] 



Coolidge, Vital Statistics of War. 



S3 



for although the precise data are not at the command of the writer in either 
case, he is familiar with the details of the official returns of the one army, 
and knows little or nothing respecting the records of the other. That the 
average assumed does approximate somewhat to the true one for the British 
army, may, with some reason, be inferred from the fact, that the annual loss 
per cent, in officers and men, calculated upon that basis, approximates the 
loss sustained by that army in the Peninsular war. In a paper compiled by 
Mr. Edmunds from returns in the Adjutant-G-enerars office — quoted by Sir 
George Ballingall in his work on Military Surgery — it is stated that, "in 
the Peninsular army, averaging a strength of 64,227, including officers and 
men, the annual ratio of mortality, from the 25th December, 1810, to the 
25th May, 1813, was ten per cent, of the officers and sixteen per cent, of the 
men." On the basis assumed in this table, the annual mortality of officers 
is 9.48 per cent., and that of the men 20.64 per cent. 

In stating the average number of volunteers in the field at one-half their 
aggregate strength, the error, if any, is in favour of the volunteers; for if, as 
the writer believes, their average force was less than that assumed, the ratio 
of mortality would be higher. The difference in the loss of life and of health 
between regular and irregular troops, shown in these tables, is, in the most 
favourable view, and with every allowance for error in the returns, sufficiently 
great to render the fact one of national importance. 

Since the above was written, the report of the Minister of War to the 
Emperor of France, respecting the affairs of the Army of the East, has been 
received. As that report gives the aggregate number of deaths occurring in 
the army, without designating separately those who were killed in battle or 
died of wounds, no attempt has been made to incorporate the French statis- 
tics in these tables. 

The report shows that France sent 309,268 soldiers to the seat of war. 
Of this number 62,492 died previous to the declaration of peace, March 30, 
1856, and 4,564, between that period and the final evacuation of the Crimea, 
July 5, 1856; making 67,056 deaths. If to this be added the missing, and 
those lost in "la Semillante," we have a total loss of 69,229 men. There 
returned to France 65,069 men, " on leave or on sick leave." This class is 
supposed to correspond with the " Invalided Home" of the British, and the 
" Discharged for Disability," of the United States returns, and will be so 
considered in the following table, which is intended to show the actual loss in 
effective men sustained in these wars, by France, England, and the United 
States. 



No. LXIX.— Jan. 1858. 7 



94 Hammond, Experiments with Bibron's Antidote. [Jan. 



Armt. 


Aggre- 
gate 
force. 


M'ths 
in 
ser- 
vice. 


Total 
died. 


Loss p 


. cent 


Total 
inva- 
lided. 


Loss p. cent. 


Total 
loss. 


Loss t 


. cent. 


Total. 


An- 
nual. 


Total 


An- 
nual. 




Total. 


An- 
nual. 


French . 


309, 26S 


25 


62,492 


20.20 


9 72 


65,069 


21.04 


10.08 


127,561 


41.24 


19.80 


British . 


111,313 


25 


21,097 


18.95 


9.12 


16,308 


14.65 


6.96 


37^405 


33^60 


16.05 


United States 




















Regulars . 


15,736 


26 


3,554 


22.58 


10.44 


2,155 


1Mb 


6.21 


5,709 


36.27 


16.68 


Additional Force 


11,186 


15 


2,264 


20.23 


16.20 


881 


7.87 


6.24 


3,145 


28.10 


22.44 


Volunteers and 




















Vol. Staff 


73,532 


10 


7,078 


9.62 


11.54 


9,216 12.53 

I 


15.03 


16,294 


22.15 


26.57 


Total, U. S. Army 


100,454 




12,896 


12.83 




12,252 


12.19 




25,148 


25.02 





Fort Riley, Kansas Territory, November, 1857. 



Art. IV. — Experiments with Bibron's Antidote to the Poison of the Rattle- 
snake. By William A. Hammond, M.D., Assist. Surg. U. S. Army. 

Some four years since, Prince Paul, of Wurtemberg, the celebrated natural- 
ist, communicated to my friend, Mr. De Vesey, the results of some experi- 
ments performed before the French Academy of Sciences by Professor Bibron, 
relative to an antidote to the poison of the rattlesnake. According to Prince 
Paul, Professor Bibron allowed a rattlesnake to bite him in the lips, cheeks, 
&c, and, by taking the antidote discovered by him, prevented all alarming 
symptoms, and, in fact, suffered no inconvenience therefrom. 

The antidote in question, as stated by Prince Paul, is prepared according 
to the following recipe: R. — Potassii iodidi gr. iv; hydrarg. chloridi corros. 
gr. ij j bromini $v. — M. Ten drops of this mixture diluted with a table- 
spoonful or two of wine or brandy constitute a dose, to be repeated if necessary. 
It must be kept in glass-stoppered vials well secured. 

Prince Paul forwarded a small quantity of the above mixture to Mr. De 
Vesey, who used it successfully in the cases of two men bitten by rattlesnakes 
near his residence in Iowa. 

During a recent expedition to the Bocky Mountains, I had several oppor- 
tunities of testing its efficacy, and, since my return, have performed additional 
experiments with it. The results have been, upon the whole, exceedingly 
satisfactory, and I think that when taken in time it may be entirely depended 
upon in the poisonous wounds of the rattlesnake, and, perhaps, also in those 
of other venomous serpents. 

1st Experiment. — Heinrich Brandt, Acting Hospital Steward, was bitten, 
on the 2d of July, 1857, in the index finger of the right hand by a large rat- 
tlesnake (crotalus confluentus), which he was in the act of putting into a jar 
for preservation. The snake inflicted a very deep wound, and hung by his 



1858.] 



Hammond, Experiments with Bibron's Antidote. 



95 



fangs to the finger for a second or two before it could be detached. About 
four miuutes after the bite, and before much pain or swelling had ensued, I 
administered one dose of Bibron's antidote. The symptoms almost immedi- 
ately disappeared. Forty minutes after giving the first dose the pain and 
swelling returned attended with considerable throbbing. I repeated the 
medicine, and in less than five minutes the finger had regained its natural 
appearance, and all pain and pulsation had vanished. He remained perfectly 
well and resumed his duties in an hour from the reception of the injury. 

2d Experiment. — A very large rattlesnake was made to bite a young wolf 
(Canis occidentalis), about three months old. The serpent wounded the ani- 
mal severely in the left flank. Fifteen minutes after the bite the leg was 
much swollen, and the wolf exhibited signs of great uneasiness, yawning, 
stretching, and looking about in an anxious manner. These symptoms con- 
tinued to increase in intensity till inability to stand, drowsiness, and slight 
convulsive movements ensued. I now (thirty minutes from the infliction of 
the wound) gave six drops of the antidote, with the almost instantaneous dis- 
appearance of the observed symptoms. In a few minutes afterwards the ani- 
mal ate a large piece of meat. 

2>d Experiment. — On the following day the same snake was made to bite 
the wolf three times in the space of five minutes, in the flank, neck, and chest. 
In two minutes after the last bite the effects of the poison were evidenced by 
the inability of the wolf to stand, gasping respiration, and a fixed expression 
of countenance. Some delay occurred in getting the antidote ready, and 
before I could administer it all signs of life had apparently ceased. Never- 
theless, I placed six drops far down the throat where it seemingly remained, 
as no effort of swallowing was perceived. However, in one minute respira- 
tion again commenced, and the heart could be felt to pulsate. The wolf lived 
for twenty-seven minutes, and then died comatose. 

The rapidity of the action of the poison in this case, owing to the large 
quantity introduced into the system, prevented a successful issue. The good 
effects of the antidote were, however, sufficiently apparent to every observer, 
and I have no doubt that, had it been given before the faculty of swallowing 
was lost, the life of the animal would have been saved. 

4:th Experiment. — After my return to Fort Riley, a large Crotalus conflnen- 
tus, which I had brought with me from the Rocky Mountains, was made to 
bite a dog five months old. The wound was made in the right shoulder. The 
poisonous effects of the bite commenced in ten minutes, causing gasping respi- 
ration, inability to stand, &c. I attempted to give a dose of the antidote but 
the dog would not swallow, and I had no means at hand by which to intro- 
duce it into the stomach. I again tried to administer the remedy but with- 
out success. The third dose was inhaled into the lungs. By this time the 
dog was perfectly senseless, and was dead in forty-five minutes after the in- 
fliction of the bite. Very slight swelling occurred in the wounded part. 

bth Experiment. — Forty-five minutes after the last experiment the same 



96 



Hammond, Experiments with Bibron's Antidote. 



[Jan. 



snake was made to bite another dog of the same litter as the preceding. The 
wound was inflicted in the lower jaw very near the mouth. At the end of 
three minutes, and before any violent symptoms ensued, a dose of the anti- 
dote was given. The dog swallowed it readily. Five minutes afterwards the 
animal seemed very uneasy. Respiration was accelerated, and he preferred 
to lie down in the shade. At the end of about fifteen minutes he could stand 
with difficulty ; and, as the sickness appeared to be on the increase, another 
dose was administered. Nearly half of this was lost. Slight swelling was 
now perceived in the face and neck. When roused the animal would walk a 
few yards though with great difficulty, and evidently preferred rest and quiet. 
About one hour after the bite he lapped a little milk and seemed to be better, 
wagging his tail when spoken to, and walking with less effort. No increase 
of the symptoms occurred, and, in fact, the dog was, to all appearance, per- 
fectly well in two hours after the reception of the injury, except that slight 
swelling of the under jaw still remained. I saw him no more till next morn- 
ing, when this had disappeared, and he was as active and lively as ever. 

I had no further opportunities of repeating the experiments with other ani- 
mals. During my absence, however, the antidote was used by Dr. Coolidge, U. 
S. Army (to whom I am also indebted for assistance in the latter experiments), 
in the following case, of which he has favoured me with the subjoined ac- 
count: — 

"In July, 1857, a girl, aged fifteen years, was bitten at Fort Riley, by a 
rattlesnake, on the dorsal aspect of the first phalanx of the ring finger of the 
right hand. In a few moments the finger became swollen and bluish, and 
when I first saw her, about ten minutes after the receipt of the wound, the 
forearm had begun to swell, and pain extended to the elbow. She was de- 
pressed and somewhat nauseated. An elder sister had sucked the wound 
from the first instant. There being sufficient space above the wound, I ap- 
plied a cord tightly around the finger, and then made a free incision down to 
the bone. As soon as the articles could be procured from the hospital, I gave 
10 drops of the bromine mixture diluted, and injected into the wounded 
finger the preparation recommended by Dr. David Brainard, of Chicago, Illi- 
nois. (See Annual Report, Smithsonian Institution, 1854.) Yiz: R. — Iodinii 
gr. x; Potasii iodidi gr. xxx; Aquas destillatse fjj. Solve. The patient 
expressed herself relieved after the first dose of the bromine; a second was 
given in twenty minutes. The solution of iodine injected caused severe 
smarting pain; the fluid and air from the syringe could be felt a little above 
the wrist, and ultimately caused suppuration of the cellular tissue on the back 
of the hand. Nothing more was done. The girl recovered." 

In conjunction with the mixture referred to in this paper, it will be 
observed that Dr. Coolidge laid open the wound and injected the cellular 
tissue with tincture of iodine, as recommended by Dr. Brainard, of Chicago, 
so that the favourable result in this instance cannot be attributed solely to 
the use of Bibron's antidote. 



1858.] 



Waring, National Hotel Endemic. 



97 



Art. V. — National Hotel Endemic. Autopsy; with Remarks. By Jas. J. 
Waring, M. D-, Washington, D. C. 

It is well known that a singular disease broke out in one of the most 
popular and frequented hotels in the city of Washington, at a time (in 
the months of January and March of the Inauguration year) when that 
hotel was most densely crowded with the distinguished and known from 
every section of our common country. So universal and yet so local was 
the disease that scarcely an individual escaped who remained for any length 
of time within the walls of the hotel; whilst not a case is on record as oc- 
curring out of its precincts, however near. This morbific agent, so powerful, 
so all pervading, and yet boxed up within four narrow walls, what was it? 
Much abstract and pointed discussion has arisen as to the nature of this 
agent, some supposing it to be a mineral poison— arsenic or some of its pre- 
parations; others to be a miasm created by the defective sewerage (notori- 
ously bad) and accumulated by the defective ventilation (equally bad) of 
that hotel. By accident I was present at and took an active part in the 
only autopsy made, to my knowledge, upon any victim of this strange dis- 
ease. Major G-eorge McNeir, aged 64, a citizen of Washington, dined at 
the hotel about the period of its first outbreak. No period of incubation 
intervened for him. The disease manifested itself before retiring to rest on 
the very day of the fatal dinner, and never left him afterward. An autopsy 
in such a case was of evident interest, not only to the scientific but 
to the general public. Therefore, by the request of Drs. R. K. Stone and 
J. E. Morgan, the committee appointed by the Board of Health to investi- 
gate this matter, the following gentlemen attended to aid in conducting it, 
viz: Dr. Wm. Jones, President of the Med. Society, D. C, and Attending 
Physician; Thos. Miller, Prof, of Anatomy, National Medical College; Prof. 
E. W. Hilgard, Analytical Chemist, Smithsonian Institution; Dr. C. F. 
Force, Commissioner of Health; Dr. Jas. J. Waring, Prof, of Physiology, 
Nat. Med. College. 

Some few weeks afterward notes of the autopsy were sent to me by Dr. 
B. K. Stone, with the request that I would make some report of them, stating 
at the same time the following as his reasons for so doing : " 1st, that I had not 
seen or treated a single case of the disease, and up to the time of the post 
mortem had not been specially interested in anything referring to it; 2d, that 
I was not a member of the Board of Health, who had already published its 
opinion of the cause of the endemic; therefore that I would not be influ- 
enced to make use of the material here so opportunely afforded to protect or 
sustain a previously expressed opinion or foregone conclusion." Desirous of 
carrying out the wishes of Dr. Stone, so expressed, my comments are made 
solely and entirely in reference to the history, symptoms, and pathology of 



98 



Waring, National Hotel Endemic. 



[Jan. 



the present ease. The history and symptoms are given in the following let- 
ter : though not communicated by one in the profession, they are described 
graphically and with sufficient accuracy. 

Washington, June 20, 1857. 

Dr. Wm. Jones: 

Sir: At your request we (my mother, brothers and sisters) herewith furnish 
you with our recollections of the symptoms, &c. attending the illness of my 
lamented father, which resulted in his death on the morning of the 12th inst. 
It may not be out of place to preface our recollections with a statement of the 
fact that up to the commencement of his late sickness he had enjoyed most 
remarkable health, never having, within our recollection, been confined two 
successive days to his bed. 

On the 8th of January last (in company with a friend who was attending the 
Convention of the Soldiers of the War of 1812) he dined at the National Hotel 
in this city: returning home between 9 and 10 o'clock that night, he complained 
to my wife of nausea, and great pain in the stomach (my mother being with 
my sister, who was quite sick): after undressing he called for a basin and 
chamber, which were furnished him, and my wife left his room: returning soon 
after, she found him leaning against the bed and still complaining of suffering 
much pain, so much so as to need her assistance in getting to bed: the cham- 
ber indicated that he had had a copious evacuation. The next morning my 
wife carried his breakfast to his room: he ate but little, and stated that he had 
had frequent evacuations during the night, and still complained of the pain and 
nausea. My wife suggested to him that he had probably indulged his appetite 
too freely the previous day at the hotel. He stated to her that he ate very little 
meat, but ate heartily of soup, and particularly of float. I myself heard him 
say that before going to the table he went to the bar of the hotel and drank 
either whiskey or brandy. 

About 9 o'clock he went out, as usual, to attend to his business, but soon 
returned, very much debilitated. He continued to complain of the pain and 
sickness, and suffering from frequent discharges from the bowels; also com- 
plained of great thirst, and burning in the mouth and throat, which created a 
constant desire for ice water. The symptoms as above stated continued with- 
out intermission (the frequency of the evacuation to some extent restrained by 
the use of. laudanum) until Sunday, Feb. 8, on which evening he was much 
prostrated by frequent and copious discharges — so much so that he fainted un- 
der the operations, in which state you saw him and administered to him. This 
attack confined him to his bed ei^ht or ten days, from the prostration of which 
he never fully recovered ; but the disease appeared to gain upon him, rendering 
his nights almost sleepless on account of the frequency of his stools, notwith- 
standing he was, on an average, taking 75 drops of laudanum a day. About 
this time, in addition to his other symptoms, he complained of a hardness or 
enlargement of the abdomen or liver, also of great internal heat. Although at 
this time very feeble, he attended partially to his business until about the 1st 
of March, when he again was brought to his bed, and on the night of the 2d 
of March was so ill as to require the family to be up with him all the night. 
This attack confined him to his bed and room until about the 10th of March, 
and left him with a fever, from which his feelings induced him to believe that 
he was rarely if ever free. From this time he frequently complained of acute 
pain in his extremities: about this time he was also taken with a cough, which 
increased rapidly and was at times very troublesome, particularly in his last 
illness. His face, which up to this time — say middle of March — was appa- 
rently bloated, and his complexion muddy and unnatural, now became very 
clear and transparent, remaining so for several days, when it again assumed 
the former muddy and unnatural appearance, accompanied with great dulness 
of the eyes and a heaviness of the brow. 

At the beginning of his illness he had very little or no appetite, but during 
the last several months it became so great that he could scarcely satisfy it, 
although he indulged it to a very great extent. His great desire for ice water 



1858.J 



Waring, National Hotel Endemic. 



99 



was produced no less by thirst than by the great burning, which he frequently 
described as eommencingat the roof of his mouth, and continuing in a straight 
line to his stomach, which sensation continued to increase up to his death. 

The interval, say from 1st April to his death, was mostly passed in bed, or 
in his room, during all of which time he suffered greatly from an almost con- 
stant pain in the stomach and bowels, as well as from the great burning in the 
mouth and throat. 

On the 4th of June the disorder of the bowels became greater than usual, and 
on the night of the 5th for the first time he passed blood, which discharges 
continued at intervals of about a half hour, until to within a few hours of dis- 
solution, which occurred on the morning of Friday, the 12th inst. 

I remain, &c. &c. &c. THOS. S. McNEIR. 

The points of interest in the above recital may be summed in a very few 
words. It is to be observed that whilst sickness, nausea and pain are spoken 
of no mention is made of vomiting. Moreover a copious evacuation marked 
the very first step in the disease, and its frequent recurrence is evidently 
dwelt on as the symptom : nausea simply continued. Throughout the day 
which succeeded the onset of disease the discharges were still frequent, and 
now he complained of a symptom so common in profuse diarrhoea — great 
thirst and burning in the mouth and throat. These symptoms, viz., thirst, 
burning, and frequent evacuations (to some extent restrained by laudanum), 
we are told continued without intermission for thirty days, when the great 
symptom — the copious evacuations — became aggravated to such a degree as 
to produce complete prostration, even fainting. This prostration, these eva- 
cuations, continued occasionally checked and again aggravated, according to 
the history, till his death. Fever appeared 62 days after the onset of the 
disease, and continued sufficiently to be noted by the patient to the end. In 
the onset of all disease, perturbation of the functions causes loss of appetite, 
but when the system becomes accustomed to a drain inordinate appetite suc- 
ceeds. Such was the fact in the case of McN. He was not compelled to 
keep his bed until the 1st of April, three months after he took sick, and 
during this time occasionally attended to his business. He commenced to 
pass blood from his bowels only eight days before his death, and he died five 
months after having eaten and drank and breathed within the walls of the 
National Hotel. 

Summary. — The earliest and throughout the most prominent symptom 
was a simple but profuse diarrhoea, with its concomitants, insatiable thirst, 
burning in the mouth and throat, inordinate appetite, and complete prostra- 
tion. Death was the result of the exhaustion of that profuse diarrhoea and 
of the steadily but slowly progressing disease of which that diarrhoea was 
but a symptom. No fever appeared for 62 days after the attack, and then 
it was obscure, not violent. Blood was passed 129 days after. Death oc- 
curred in 131 days. 

What mineral poison will produce such a series of symptoms? What 
miasm is known to produce such a disease? 

Autopsy, 16 hours after death. — Temperature 80°. On laying open the 
abdominal parietes the peritoneum, both visceral and parietal, was found 



100 



Waring, National Hotel Endemic. 



[Jan. 



discoloured, red, but varying in intensity in different parts; it was by far the 
most marked on the surface of the transverse colon ; here it deepened in 
intensity almost to a purple hue. The great omentum was decidedly con- 
gested, and darkened of a dark red hue. The appendieae epiploicae were 
also congested and red. The colon, as before remarked, was externally of a 
dark red, whilst the stomach and lesser omentum were perfectly normal in 
colour. This colour existed on the surface of the ascending and descending 
colon, but to a much less marked degree, except at the caecum and sigmoid 
flexure, where the colour again deepened, though not to the same intensity. 
There was no effusion in the abdominal cavity of either coagulable lymph 
or fluid. 

Stomach. — On opening the alimentary canal we found — -in the stomach, no 
ingesta but a little mucus and discoloured fluid. The mucous membrane was 
slightly thickened near the pyloric orifice, but was not softened. It was of a 
dirty gray colour with stellated points of congestion near the cardiac orifice. 
On the lesser curvature and posterior wall, and midway between the cardiac 
and pyloric orifices a circular ulcer existed, deep, with sharp undermined edges 
and with a fungous growth of exuberant granulations overhanging and pro- 
jecting. The ulcer penetrated to the muscular coat, which formed for it a 
smooth base. 

Duodenum. — A bright saffron yellow fluid, homogeneous and abundant, 
filled the duodenum. This viscus was perfectly healthy in appearance, and 
stained with healthy bile. 

Jejunum. — -The contents were mucoid, and of a duller yellow hue. In 
the first few inches, the valvulse conniventes were reddened. The solitary 
glands were enlarged and distinctly prominent, looking like large pins' heads. 
Peyer's patches were remarkably distinct. These glands did not seem so 
much to be diseased as to have been diseased. There was a deposit of pig- 
ment in spots dotting over their whole surface, and they were slightly pro- 
jecting. There was no ulceration or marked softening of the mucous mem- 
brane, and the coats were not much thickened. 

Ileum. — The whole course of this intestine was in a perfectly healthy 
condition. The contents were thicker than in the upper portions of the 
alimentary canal, containing fresh and healthy-coloured bilious matter. The 
glandulag agminatae were universally and distinctly marked, looking pre- 
cisely as they did in the jejunum, but much more abundant. 

Caecum and Colon. — The ileo-caecal valve was in an ulcerated state, an 
honey-comb like ulceration in myriad spots. These little ulcers were circu- 
lar, and did not penetrate beyond the submucous cellular tissue. The coats 
of the caecum and commencing colon were enormously hypertrophied, more 
especially the muscular and cellular. There was a reddish and fungoid ele- 
vation and thickening here and there of the mucous membrane. In the 
colon, just beyond the caecum, for 5 inches in total length, and 9 or 10 in 
number^ partly upon and partly between the rugae were seen transversely 



1858.] 



Waring, National Hotel Endemic. 



101 



linear projections of the mucous membrane. These were hard, prominent, 
granulated, and ulcerated, so as to give an honey-combed appearance. Their 
surface was of a dark-brownish red colour. These placqites were from g inch 
to an inch in length, and from a £ to £ in. broad, and elevated about £ in. 
above the mucous surface. The transverse and descending colon was simi- 
larly diseased. The mucous coat was much thickened, and covered with 
minute ulcerations, circular in character, and in no case penetrating beyond 
the submucous cellular tissue. The ulcer mentioned as existing near the 
cardiac orifice of the stomach alone evidenced a tendency to perforation. The 
transverse colon was more decidedly congested and diseased than any other 
part of this intestine except the caecum before described. Here too the 
little ulcers were so abundant and so closely set that they became fused 
together, so as almost to lose their circular character. It was matter of 
astonishment to observe the extent of surface denuded of mucous membrane. 
It remained intact only in patches, and yet the denuded cellular coat had no 
where ulcerated beyond the muscular coat. The rectum presented the same 
marks of disease as the caecum. 

All the other important organs of the body, as heart, lungs, liver, &c, 
were in a healthy state; no further lesions of any kind were found. 

Such an autopsy could not but impress me with certain convictions. 
These I have attempted, though imperfectly, to embody in the following 
remarks. 

In the stomach of McN. no evidences existed of previous or present gas- 
tritis; no evidences of the application to its coats of any corrosive substances. 
This too is in perfect accordance with the symptoms during life. The circular 
ulcer found on the lesser curvature and posterior wall, and midway between 
the cardiac and pyloric orifices was recent, and corresponds to the perforat- 
ing ulcer of Budd and Rokitansky, and the chronic gastric ulcer of Cruveil- 
hier. The following quotations will make this more than probable. 

Diseases of the Stomach, by George Budd, M. D., F. R. S. American 
edition. (Pages 91, 92.) 

" In most cases, the stomach presents no marks of disease, except a single 
ulcer on its inner surface. This ulcer is seldom larger than a shilling, but 
sometimes, especially when it is situated on the posterior wall of the stomach, 
grows to the size of a crown piece, or even larger than this. It is generally 
circular or oval, and in all cases extends through the mucous membrane, the 
edges of which are clean-cut as if a portion of the membrane had been punched 
out; sometimes the mucous membrane only is destroyed, and the ulcer has 
then an even base, formed of the submucous cellular tissue. * * * * The ulcer 
is generally situated along the lesser curvature of the stomach, or near it ; 
usually nearer the pyloric orifice than the cardiac ; and much more frequently 
on the posterior wall of the stomach than on the anterior." * * * " In most 
cases of simple ulcer of the stomach the ulcer is solitary." 

See also Rokitansky, vol. ii. page 36, American edition, for precisely 
similar quotations. 

We stated, it will be remembered, that no evidences existed of inflamma- 



102 



"Waring, National Hotel Endemic. 



[Jan. 



tion in the stomach; the duodenum, jejunum, and ilium, in like manner, 
presented no evidences of inflammation of any kind. One lesion of marked 
interest presented itself, however ; this was the enlargement and development 
of the solitary and agminated glands. Peyer's patches were scattered over 
with black spots, as if from previous ulceration and eventual healing, with 
a deposit of black pigment in the little cicatrices. 

The seat of the true disease which produced the death of McN. was evi- 
dently not above the ileo-caecal valve. The moment, however, this narrow 
boundary is reached, extensive disease presents itself. Honey-comb like 
ulcerations of the mucous membrane on the very edge of the valve, and 
continuing with the same characters, though even more extensive, up and 
around to the rectum; thickening of all the coats beyond this point, even 
forming thick dark red ridges for some distance beyond the valve ; red con- 
gestion of these coats through to the peritoneum ; congestion and irritation 
if not inflammation of the peritoneum — these were some of the results of 
this disease. The thickening of the coats referred to was most marked in 
the caecum and rectum ; the coats were thicker however in the transverse 
colon than in either the ascending or descending colon. The transverse 
colou, cascum, and rectum, were plainly the chief seats of disease. The 
coats through to the peritoneum in these parts were intensely red, especially 
those of the transverse colon. The congestion of the peritoneum was plainly 
due to a transmission of irritation or inflammation through the mucous, 
cellular, and muscular coats. It should be noted that there was no fluid in 
the peritoneal sac, and no secretion of plastic lymph or pus, the usual results 
of inflammation, and yet the great omentum was reddened and darkened, 
showing that this irritation was rapidly becoming of a very serious nature. 

The disease plainly commenced in the mucous coat, affecting the other 
coats only from contiguity of surface. A wider conclusion may still further 
be drawn from this case. Death was the result of the extensive disease of 
the mucous coat of the large intestine. The external agent, whatever it 
was, seems to have confined its ravages entirely to this intestine, commencing 
on the very edge of the ileo-caecal valve, and terminating only at the sphinc- 
ter ani. Further we may conclude, by combining the symptoms with the 
known pathology that the cause, whatever it was, attacked at the very out- 
set the mucous membrane of the large intestine, and did not produce any 
change in the stomach and small intestines, sufficient to affect or modify the 
symptoms, which were the result solely of the lesions in the large intestine. 

The perforating gastric ulcer was recent, and no doubt the result of the 
depraved and weakened constitution of the patient. It is possible that the 
changes in the glands of the small intestines were the result of some typhoid 
condition of the blood, possibly of an irritation transmitted to them from 
the colon. 

The mucous membrane of the large intestine was so extensively ulcerated 
in places as to be left only in little islets, whilst in other places these ulcera- 



1858.] 



Waring, National Hotel Endemic. 



103 



tions assumed the form of circlets, leaving the membrane otherwise intact, 
and giving the honey-combed appearance, before referred to. In fact the 
destruction of this membrane was so extensive that it became matter of 
astonishment the individual could live at all with such a condition of things. 
These myriad ulcers, whether small and well-defined, or large and more 
irregular, yet invariably affected the circular form, did not penetrate beyond 
the submucous cellular coat, and presented at their bases neither softening, 
darkening exudation, nor other evidences of a tendency to penetrate further 
or perforate. 

Eokitansky, whose authority in pathology none will doubt, speaks of four 
distinct forms of inflammation of the large intestine, viz : a, erythematous ; 
h, exudative; c, typhous; d, dysenteric. Under which of these forms should 
we classify the disease before us ? The following quotations, I think, will 
determine : — 

" Catarrhal (erythematous) inflammation — or, in a lower degree, mere catar- 
rhal irritation, catarrh — presents itself as genuine entero-catarrhus, with a dis- 
charge of a thin muco-serous secretion in catarrhal diarrhoeas, namely, as a 
consequence of suppressed cutaneous exhalation. It may result from mechani- 
cal or chemical, &c. &c." * * *; "or, lastly, it frequently shows a specific, 
contagious property (exanthematic typhoid catarrhs) * * "Catarrh is either 
acute or chronic, and it either attacks the mucous membrane uniformly, or is 
developed mainly in the villi and follicles. * * * Chronic inflammation rarely 
admits of a complete cure. It is generally followed by a blennorrhoeic condition ; 
and we thus find, in well-marked cases, a permanent dilatation of the vessels 
established, with the following alterations in the tissues :" * * * 

"Increase of substance, or permanent tumefaction of the mucous membrane, 
its follicles, or villi, with increased density and consistence (hypertrophy), 
giving rise in higher degrees to elongation of the membrane and formation of 
folds and polypi ; hypertrophy of the submucous cellular tissue and the mus- 
cular coat, &c. &c." * * * 

"The seat and extent of the catarrhal inflammation and of the blennorrhoea, 
differ according to the cause." * * * " They are not common in the small in- 
testine, their usual seat being certain portions of the large intestine, viz., the 
caecum and rectum. A peculiar disease, which we must here advert to, is 
ulcerative inflammation of the follicles of the colon, such as we find in lientery, 
brought on by tedious diarrhoeas. An ulcer results, which is distinguished 
from the catarrhal ulcer just described, by the shape which it derives from the 
follicle, and still more by the total absence of reaction, which is brought on by 
the excessive destruction of tissue, and which produces an atonic and relaxed 
state of the tissues at the base. In this disease, which in the dead subject is 
commonly not observed until it has committed extensive ravages, the follicles 
are at first tumefied in various degrees, and consequently project as smaller or 
larger round conical nodules on the internal surface of the intestine, being 
surrounded by a dark red halo. Ulceration now ensues in the interior of the 
follicle, the small abscess penetrates the mucous membrane within the vpscular 
halo, and a fringed ulcerated opening of the size of a millet-seed appears, which 
leads to a small follicular abscess with red spongy walls. The ulceration con- 
tinues, and the follicle is eaten away." * * * The ulcer is of the size of a 
pea or lentil, round or oval, the mucous membrane at the circumference is 
pale, slate-coloured, livid, and much relaxed ; the cellular tissue at the base is 
dull-white, anasmic, sanguineous or dark blue. At this period a secondary de- 
struction of the intestinal mucous membrane commences, which proceeds with 
great rapidity. The original follicular ulcer now enlarges." * * * "Several 
ulcers coalesce." * * * "The most extensive destruction is found to occur in 



104 



Waring, National Hotel Endemic. 



[Jan. 



the sigmoid flexure and the rectum. It is always confined to the colon." * * * 
" On account of the alvine discharges, which are invariably associated with 
this ulcer, the affection may not inappropriately be termed ulcerative diar- 
rhoea." 1 * * * ' 1 L ' 

It must be evident to those who have read the above quotations, that the 
disease of which Major George McNeir died was a superficial erythematous 
or catarrhal inflammation of the mucous membrane of the large intestine. 
The attack assumed the chronic form, and lasted 131 days. It evidently 
also had its seat in the follicles of the large intestine, and plainly corresponds 
to the disease called by Rokitansky " Follicular Erythema or Catarrh" of 
the large intestine, or "Ulcerative Diarrhoea." 

Could arsenic, in any of its forms, whether introduced into the stomach, 
into the blood directly, or inhaled in the form of arseniated hydrogen, pro- 
duce such a disease? Nothing can be more easily answered. Consult Tay- 
lor, Christison, Budd, Rokitansky, &c. 

Every candid mind must agree that it cannot. Can, then, foul emanations 
from bad sewers, pent up and breathed only for four or five hours, produce 
such a disease ? I confess myself incapable of producing a single authenti- 
cated case where such a cause was followed by such a disease. Yet I leave 
this subject with my mind convinced, even though this be a new observation 
of the mysterious effects of miasm, that this and this alone was the cause of 
the death of the unfortunate gentleman, the subject of the present comments. 

We append the following letter from Dr. J. C. Hall, of Washington, D. C, 
who was so fortunate as to attend a large number of those affected by this 
disease during the whole period of its continuance. His observations led 
him to a certain conclusion already published. He now kindly communi- 
cates a fact which confirms him in his previously expressed opinion. 

"Washington, Nov. 30, 1857. 

Dear Doctor: The National Hotel was closed about the first of April, and 
the furniture was sold in the rooms about the middle of June. I am informed 
by the auctioneer that he and several of his assistants were attacked with a 
diarrhoea similar to that which prevailed in the house during the winter. They 
neither ate, nor drank in the house. This fact (of which I have no doubt), to 
my mind, affords conclusive evidence of the atmospheric or miasmatic theory 
of this very peculiar disease. Yours, truly, 

Dr. Waring. J. C. HALL. 

1 Rokitansky, vol. ii. pp. 59, 60, 61, American edition, 1855. 
Washington, D. C, Nov., 1857. 



1858.] 



Gilbert, Adhesive Plaster in Fractures of Thigh. 



105 



Art. VI. — Adhesive Plaster the best Counter-extending Means in Fractures 
of the Thigh. By D. Gilbert, M. D., Professor of Midwifery in the 
Medical Department of Pennsylvania College. 

Since the publication of my first case of severely complicated fracture of 
the thigh (Am. Jonrn., Jan., 1851), in which adhesive plaster was so suc- 
cessfully used in keeping up extension and counter-extension, I have had 
numerous opportunities of testing its value and confirming the good opinion 
then formed of it. In every case the necessary tension, however great the 
muscular resistance to be overcome, was kept up without abrasion of the sur- 
face, or pain as the result of pressure. In the cases of adults, or even younger 
persons, who could appreciate the importance of quietude in the treatment, 
these perineal bands seldom required renewal during the entire period of con- 
finement. Adhesive plaster, when well applied to the surface, becomes united 
with the skin, so as to form a composite body; consequently friction and pres- 
sure are transferred to the areolar, adipose and other tissues beneath. These 
are characterized by histological and physiological endowments which fit them, 
in a peculiar manner, for the toleration of pressure and motion without pain 
or anatomical disturbance or lesion. The skin is thus protected, and, conse- 
quently, abrasion, excoriation, or ulceration, either or all of which are the 
usual products of pressure and friction upon its surface, when the ordinary 
perineal bandages are used, do not occur. The adhesive bands, moreover, 
act upon a surface much more extensive than that of their mere attachment, 
through the elasticity of the skin, and thus contribute still more to its pro- 
tection in protracted extension and counter-extension. All who have treated 
fractures of the lower extremities must admit that freedom from suffering at 
the seat of counter-extension is a great desideratum; this being secured, 
another, equally important, viz., continued quietude of the fracture after 
reduction and the adjustment of the retentive apparatus, is also attained. 

The following cases, which are extraordinary in their character, have been 
selected for publication at this time, in order that the attention of the pro- 
fession may be more fully directed to the subject, and to demonstrate the 
great value of the plan in cases of extreme difficulty. 

Case I. — C. Youngandrews, of N. 9th Street, aged eleven years, fell on 
the street and fractured his thigh obliquely, above its central part, June 12th, 
1852. D. M.' Fort, M.D., of Vine Street, became, at my request, associated 
with me in the case, both having been sent for simultaneously. The splint 
and apparatus described in my former communication, including adhesive ex- 
tending and counter-extending bands, were applied. No pain, except at the 
seat of fracture, was complained of. In four and a half weeks the splint was 
permanently removed, complete union having taken place. During this period 
the anterior or upper counter-extending adhesive strip only required renewal. 
The cure in this case was not only accomplished in an unusually short period, 



106 



Gilbert, Adhesive Plaster in Fractures of Thigh. 



[Jan. 



which is mainly attributable, in my opinion, to the perfect quiescence secured 
by this method, but it is the more remarkable since this boy was slightly non 
compos, and, ordinarily, very difficult to control by his parents. 

Case II. — Dr. Fort was so well pleased with the method by adhesive plaster, 
that he used it in the following case, which he has kindly furnished to me: — 

A twin daughter, aged eighteen months, of Mr. D. Steinmetz, of this city, 
fell out of bed, May 29th, 1853, and fractured her right thigh near the 
trochanter. The fracture was reduced, and retentive apparatus, precisely as 
in the case of Youngandrews, was applied. In thirty days the cure was com- 
plete. The anterior counter-extending strip required renewal once during the 
treatment. 

Case III. — The late Dr. N. C. Nancrede, of this city, requested me to 
meet him in consultation, June 9th, 1858, at the residence of Mr. A. Sieber- 
lich, in Spruce Street. The infant son of Mr. S., aged seven months and a 
half, had fallen out of bed and fractured his thigh about its middle. The 
fracture was evident from the deformity and shortening. The following re- 
tentive apparatus was prepared. One light splint, about one and a half inch 
wide, to be applied from the crista of the ilium to a little below the knee; 
three short splints of the same width, for the anterior, posterior and inner 
aspects of the thigh; and numerous adhesive strips, eighteen inches long and 
one and a half inch wide. The splints were padded with wadding on the 
one side, so as to adapt them to the contour of the thigh. Adhesive strips 
were used, instead of the ordinary roller, in supporting the wadding upon the 
splints. Reduction of the fracture having been effected, the long splint was 
applied to the outer surface of the thigh, and fixed there by its covering of 
adhesive plaster, and adhesive bands applied to the knee and distal extremity, 
so as to maintain extension; whilst other bands were applied to the inside of 
the thigh, perineum, groin and proximal extremity of the splint, to secure 
counter-extension. The short splints were then applied and secured in place 
by adhesive strips instead of the ordinary roller. Thus, all the splints were 
held securely in their places by the adhesive plasters which composed their 
covering, as well as by the strips which encircled them and the thigh, and 
thus extension, counter-extension and coaptation were fully maintained. The 
motion of the hip and knee-joints was free, and the child was comparatively 
free from pain, immediately after this retentive apparatus was applied. The 
patient was not only carried about the house but taken to the family summer 
residence in the country and brought to town once a week for our inspection 
and the readjustment of the dressings, which were more or less displaced by 
the incessant movements peculiar to infancy. In four weeks from their first 
application the retentive means were removed, union having taken place 
without deformity or shortening. 

Case IV. — I was summoned in great haste, May 2d, 1854. to Wm. Henry, 
aged nearly five years, son of T. N. Triall, residing in Noble above 9th St., 
who had just been run over by several coal cars on the Willow Street rail- 
road in the vicinity. The accounts of the manner in which the accident oc- 
curred were very unsatisfactory, none but children having witnessed its occur- 
rence. There was no evidence of the passage of car-wheels over any part of 
the body or the extremities. I found, upon examination, that the left thigh, 
above its middle, the tibise and fibulas of both legs and both bones of the right 
forearm were fractured. There were numerous contusions on the body and 



1858.] Gilbert, Adhesive Plaster in Fractures of Thigh, 



107 



extremities, and the fractured ends of the bones had lacerated the soft parts 
in their vicinity extensively, although the fractures were all simple. The 
usual splints, compresses, adhesive bands and rollers were applied. On in- 
quiry I learned that H. Deitrich, M.D., of 10th St., was the family physician, 
who, at my request, was sent for and became associated with me in the case. 
The splints which were hastily provided for the first dressing, after a few 
days, were removed, and Dr. Gibson's modification of Hagedorn's splint was 
substituted; which, with the adhesive bands for extension and counter-exten- 
sion, answered the indications in this case more fully than the ordinary splint, 
especially in restraining more fully the movements of the lower extremities. 
Our patient was totally unwilling to be confined, and made constant persever- 
ing efforts to disengage himself, which gave us a great deal of trouble in 
maintaining the proper adjustment of the retentive apparatus. Febrile re- 
action supervened on the second day of an active character, accompanied by 
delirium, which increased our already existing difficulties very greatly. By 
appropriate constitutional treatment and perseverance in the plan adopted to 
procure reunion of the fractured bones, this case, so unpromising in all its 
aspects in the commencement, was conducted to a happy termination at the 
close of two months, precisely, from the date of the accident, viz., July 2d. 
The splints and bandages were removed on that day, and, to my utter sur- 
prise, I saw our patient in the street with his playmates on the tenth of the 
same month. There is neither shortening nor deformity. 

Case^Y. — I was requested by B. Price, M.D., of N. 9th Street, to meet 
him in consultation September 12th, 1855, at 20th and Spring Garden Streets, 
in the case of a little girl, aged five years, the daughter of Mr. T. Kane. 
We found the left thigh-bone badly fractured in its upper third by the passage 
over it of a heavy earth-cart. The soft parts were seriously contused, and the 
deformity and shortening were remarkable. We provided a splint, about 2j 
inches wide reaching from above the crista of the ilium to several inches below 
the sole of the foot. This was padded with cotton, so as to adapt it to the sur- 
face upon which it was to be applied. Bands of adhesive plaster were used for 
extension and counter-extension, as well as to all intervening parts except the 
seat of fracture, instead of the ordinary roller. After the adjustment of these 
retentive means, the child declared itself free from pain, except at the imme- 
diate seat of injury, and was moved from room to room without seriously de- 
ranging the dressings or interfering with the fracture. This child recovered, 
without deformity, in six weeks, although placed in most unfavourable circum- 
stances as regarded ordinary attention — the father being constantly under the 
influence of liquor, and the mother having all the cares of the family resting 
upon her, without any one to aid her. 

The following cases show the value of adhesive plaster as a means of ex- 
tension and counter-extension in fractures of the leg : — 

Case YI. — Michael Gillis, drayman, set. 40 years, had compound fracture 
of both bones of the right leg, caused by a kick of his horse on the loth of 
December, 1852. Dr. Fort, of Vine Street, was called and requested my 
attendance in consultation. We found the tibia comminuted. A fragment 
measuring about one and a half inch in length, and comprising more than 
half of the diameter of the bone (tibia), was detached and required removal. 
The wound was large and ragged, owing to the fact that the horse had just 
been rough-shod. Gillis being a robust man, of large muscular development, 
very considerable extending and counter-extending force was necessary in 



108 Gilbert, Adhesive Plaster in Fractures of Thiyh. [Jan. 

effecting reduction. A modification of Hutchinson's splint, adapted to com- 
pound fractures of the leg, which I had used successfully on a previous case, 
was applied. For counter-extension four bands of adhesive plaster, about 
eighteen inches long by two inches wide, were used. These were applied 
spirally, so as to cross each other — the two anterior below the tubercle of the 
tibia, the two posterior at a point opposite; and as each one of these, in its 
spiral course, became lateral, in passing from below upwards, and from above 
down, they cross each other again directly opposite the joint, internally and 
externally, after which the balance, or the free proximal extremities, were 
passed through the holes in the upper end of the splint and securely tied. 

The bands used in extension were applied in the usual way, laterally 
and extending below the foot in the form of a short loop. This received 
the strap of the tourniquet, the framework of which rested upon a cross- 
piece attached to the distal extremities of the splints, and thus, by means 
of the tourniquet, as in fractures of the thigh, extension and counter- 
extension were kept up. In this apparatus no support was provided for the 
posterior surface of the leg except that afforded by the straw mattress upon 
which he was laid, which was unsteady. To remedy this defect Dr. Fort 
suggested the use of the common fracture-box, altered so as to admit of ex- 
tension by the tourniquet's resting upon a cross-bar below the foot, and counter- 
extension by passing the adhesive bands through the holes in the upper part 
of the sides of the fracture-box. To accomplish this the sides of the fracture- 
box were composed of three separate pieces each. The upper and lower on 
each side were firmly screwed to the bottom board, whilst the middle pieces 
only were attached by hinges. Thus, as extension and counter-extension were 
being kept up, the central segment of either side of the apparatus could be 
let fall away from the leg, and the wound exposed byopeniDg the many-tailed 
bandage, whenever this became necessary. 

The fracture box was removed at the end of the ninth week, without 
shortening or deformity. There was no pain complained of at the seats of 
extension and counter-extension during the entire treatment. 

Case YIL — I was summoned in great haste to Mr. B. F. Dutton, on the 
16th of March, 1853, who had fallen from the fifth story of Messrs. Hall & 
Boardman's factory, in Arch Street below Third, through the hatchway to the 
first floor, a distance of about fifty feet. Mr. D. is a large man, weighing 
about 200 lbs. He very imprudently tried the strength of a board which 
was laid across the opening in the floor of the fifth story by standing upon 
it. The board broke, and he fell. The force of the fall was received by 
his feet, they continuing to be the most dependent parts. The concussion 
was very profound, so that at first it was supposed he was dead. When I 
arrived reaction was gradually taking place. On a careful examination I 
found fracture of both bones of both legs near the ankle-joints. The frac- 
tures were oblique and irregular. In the right leg I had reason to believe 
that the lower fragment of the tibia was split longitudinally into two pieces. 
The malleoli were distorted in both legs, and, no doubt, the ligaments of the 
ankle-joints were extensively lacerated. There were severe contusions over 
the course of the spinal column, which were, doubtless, caused by striking 
against the floor as the body passed through the hatches. After sufficient 
reaction was established, he was conveyed on a settee, by his friends, to his 
residence in N. Twelfth Street above Poplar. 

Assisted by Dr. Royer, of Schuylkill County, who happened to be near the 
place where the accident occurred, temporary bandaging, so as to support the 



1858.] 



Sawyer, Osteoid Growth at Right Hip joint. 



109 



parts after their reduction, was applied, and cold water dressing enjoined. 
An anodyne was given. Finding, next day, when reaction became somewhat 
excessive, that the muscular contractions could not be controlled in this way, 
and that there was danger of serious displacement, adhesive plasters were 
applied in the usual manner, except that those by which extension was made 
had to be confined in their attachments to the feet alone. By means of these 
and the many-tailed bandage the eoaptated fragments were kept in place until 
it was deemed safe to use the immovable dressing, which, when applied seve- 
ral days after, answered a very good purpose in conjunction with the plan 
already adopted. On the forty-fourth day after the accident all retentive 
means were permanently removed. Mr. Dutton now has full use of his 
ankle-joints, not even using a cane in walking. 



Art. VII. — Case of Osteoid Growth connected with the Capsular Ligament 
of the Right Hip- Joint. By A. F. Sawyer, M. D., one of the Surgeons of 
the " Hospital of the Sisters of Mercy," San Francisco, Cal. (With three 
wood-cuts.) 

The patient, a native of France, set. 47 years, entered the hospital for 
treatment, March 16, 1857. He has a full adipose habit, with the general 
appearance of sound health. 

His own account of the case is as follows :— 

About a year ago his attention was directed to the presence of a small 
apparently movable tumour, on the anterior surface of the thigh in its upper 
third. At first it did not seem to increase in size, and gave him very little 
inconvenience. During the last six months, it has been rapidly enlarging, 
especially towards the ilium, attended with sharp pricking pains, exaggerated 
at night, more particularly after a hard day's labor. He has continued his 
occupation as a miner, until within a few weeks, when, becoming apprehensive 
as to the real nature of the disease, he for the first time solicited medical 
advice. He could give no rational cause for the origin of the tumour. His 
parents were healthy and long-lived ; and although his previous history has 
been one of great exposure physically, he has never suffered much from gene- 
ral sickness. The only circumstance narrated, which can have had even an 
indirect bearing on his case, is in connection with an accident he met with 
about two years previously to the development of the tumour, at which time 
he received severe injuries in the back from a mass of earth falling upon him. 
He was not, however, so severely disabled that he could not rescue himself 
unaided, and afterwards walked some distance to his cabin. Something like 
six weeks elapsed before he could resume his usual employment, suffering 
more especially from severe pains in the lumbar region, attended with some 
swelling of the soft parts, and general sympathetic fever. No pain was felt 
about the pelvis. There was no lesion of its contained viscera, and he pre- 
served an entire command over the motions of the lower extremities, without 
any symptoms whatsoever involving the ilio-femoral articulation. Within the 
last four months a lameness has gradually supervened, and latterly he has re- 
quired a cane to assist him in locomotion. 
No. LXIX.— Jan. 1858. 8 



JIO Sawyer, Osteoid Growth at Rhjlit Hip-joint. [Jan. 

On examination, there was found on the upper and anterior portion of the 
right thigh a large tumour extending from near the anterior-superior spine of 
the ilium downwards nine inches, in the direction of the long axis of the 
femur. Above, the tumour was widely expanded, apparently placed against 
the ilium, and covered in by the muscles of this region. Inferiorly, the 
tumour became gradually tapering, and its well-marked bifurcated extremity 
could be felt quite superficially beneath the skin. It had a hard cartilaginous 
consistency, and appeared to be movable, as was certainly the case in the 
lower and superficial portion of it. The integument was somewhat stretched 
over the tumour, but not discoloured. There seemed to be but little tender- 
ness, and even with rough manipulation no complaint of additional pain. 
The pain, as described, was always of a pricking character, and confined to 
the tumour itself. 

The right lower extremity was shortened five-eighths of an inch, when his 
body was in repose, yet the limb could be drawn down to correspond with its 
fellow. On rotation of the thigh, and in flexing and extending it upon the 
pelvis, a most extraordinary freedom of motion was found in the hip articula- 
tion, attended with extensive grating and crepitus, which could be heard some 
distance from the bedside. By forcible abduction and adduction of the limb, 
the head of the femur traversed the acetabulum abruptly, and with loud 
crepitus. There was certainly an unnatural laxity of the capsular ligament, 
perhaps rupture of the round ligament, and the grating indicated that the 
articulating surfaces of the joint were deprived of their natural cartilaginous 
coverings. The patient voluntarily, and without pain, could move his thigh 
in every direction ; flexing it, rotating it, etc., yet always with the same 
grating sounds. These movements of the head of the femur, jumping about 
as it were in the acetabulum, were, to say the least, very peculiar. The 
patient does not at present, nor has he ever suffered the slightest pain in the 
articulation, either in walking, or even when the head of the femur is driven 
forcibly against the acetabulum. All the pain experienced, whether in a 
reclining or upright posture, is referred directly to the tumour, and becomes 
somewhat aggravated after over-exercise of the limb. He could bear the 
weight of his body on the affected limb, and walk about with tolerable ease 
without any support. The lameness in walking appeared to result rather 
from the shortening of the limb than from any loss of direct power over its 
movements. 

He made no complaint of his general health, had a good appetite, and 
appeared strong and vigorous. Some general febrile symptoms were com- 
plained of, as thirst, dryness of skin, and constipation of the bowels. This 
condition of the system he reported as paroxysmal, although not preceded by 
chills, a remark of some importance, as the patient, during his residence in 
the mines, had often suffered from light attacks of fever and ague. Pulse 78, 
full and strong. 

In our investigation of this case we could not make a decided diagnosis, 
and we shall now briefly consider the points of certainty or uncertainty con- 
nected with it. 

The general appearance of the tumour, its position, solidity of texture, and 
particularly its bifurcated end, which was obvious to the eye as well as to the 
touch, where it protruded through the muscle beneath the integument, rea- 
sonably led to the idea of an exostosis, which had its origin from the upper 
part of the femur or some portion of the pelvis in the neighbourhood of the 



1858.] 



Sawyer, Osteoid Growth at Right Hip-joint. 



Ill 



acetabulum, an examination of the bulk of the tumour indicating deep-seated 
attachments. These positive features of the case strongly demanding the 
diagnosis of solid bony growth, having its origin in bone, were negatived by 
the single fact of mobility, which, if not fully distmct in the mass of the 
tumour, was unquestionably so in the superficial, and from the singularity of 
its formation, in this connection, its most important part, since it could be 
readily grasped by the hand, and exhibited motion quite distinct from flexi- 
bility. 

The consistency of the tumour was too great for simple sarcomatous, adi- 
pose or cystic growths; and for the same reason it was necessary to reject the 
probability of any purulent deposit, although the position might be an ap- 
propriate one for abscess connected with caries of the spine, especially in a 
case where, from the previous injuries which the back had received, we might 
have suspected the results of inflammatory action kindled up in the bodies of 
the lumbar vertebrae. The bifurcated end of the tumour forbids the idea of 
aneurism. Apart from this circumstance, it bore many points of resemblance 
in position and outline to a case of aneurism of a branch of the " profunda 
femoris" that recently fell under our observation, which was entirely without 
bruit or pulsation, and the true nature of which was only disclosed by an 
explorative puncture into it. And lastly, could it be considered a case of 
malignant disease of a fibroid nature in its primary stage of development, and 
without presenting as yet the well-marked local and constitutional signs which 
may make a diagnosis certain ? It is to be remembered that excessive pain 
and tenderness are not always necessary concomitants of malignant disease. 
One of the most extensive cases of osteo-sarcoma of the tibia that we have 
ever seen was attended with only trifling uneasiness, never sufficient to pre- 
vent rest. In this case there was no tenderness, but the nature of the pain 
was suspicious, a constant pricking pain. Added to this was the general 
character of the growth itself, and the inguinal glands were decidedly enlarged. 

With an opinion inclining in this direction as to the real nature of the 
tumour, the hip-joint now becomes an interesting study, as its extensive ana- 
tomical lesions indicated a more or less intimate relationship with the tumour, 
especially as the unnatural condition' of the articulation began to develop 
itself at a period subsequent to the appearance of the tumour. 

We have already mentioned its leading peculiarities as an unnatural mo- 
bility of the joint, associated with a decidedly bony crepitus, and a very con 
siderable shortening of the limb. A fair inference would be that the joint 
had suffered at some time previously from direct violence applied to it, causing 
perhaps fractures of the neck of the femur or of the acetabulum, complicated 
with a tearing of the fibrous textures of the joint and with more or less dis- 
placement of the bony fragments. Is it possible that from the activity of the 
inflammatory processes thus kindled up a nidus could have been formed for 
the development of the tumour? Such extensive lesions, had they occurred, 
would probably have been within the knowledge of the patient. So far from 



112 Sawyer, Osteoid Growth at Right Hip-joint. [Jan. 

this being the case, the patient noted these changes only after the tumour had 
excited his attention, and they became steadily progressive as the tumour en- 
larged, and in his narration of the injuries really received there is nothing 
that implicates the integrity of the hip-joint. Again, it was scarcely possible 
that caries could have existed from constitutional or external causes; for there 
had never been pain, swelling or tenderness about the joint, and he had always 
preserved the most entire voluntary control over the limb; such pain as was 
complained of being referred to the body of the tumour. The tumour could 
not be regarded as an abscess connected with such caries, granting its exist- 
ence, for the reasons detailed when speaking of lumbar abscess. 

If his statements were to have any value in a review of his case, we were 
rather disposed to regard this unnatural condition as resulting from the irrita- 
tion occasioned by the attachment of the morbid mass to the joint itself, or 
in its immediate neighborhood, and thus leading to a progressive absorption 
of the bone and cartilage which enters into its formation. At all events, from 
some cause or other, the acetabulum had suffered severely, and it is only by 
granting these extensive changes that the extraordinary freedom of motion 
and grating of bone in the joint could be accounted for. 

The peculiarities of this case attracted considerable attention from the pro- 
fession in this city, and we are not aware that any unlimited diagnosis was 
ventured concerning it. It was generally considered to hold an anomalous 
position in the class of affections the surgeon is called upon to treat. 

Operation. — March 21. Having determined to extirpate the tumour, and 
having previously stated to the patient the dangers to be apprehended from an 
operation, which I conceived if the disease was of a malignant nature might end 
in an exarticulation of the limb, and to the performance of which he gave his 
entire consent, he was placed under the influence of sulphuric ether. The 
thigh being placed in a position to relax the muscles, a longitudinal incision 
was made downward through the integument from a little above the anterior 
superior spine of the ilium, to the lower third of the thigh. Just above the 
insertion of the tensor vaginae femoris a second incision was made intersecting 
the former at right angles, and the flaps of skin then lifted up so as to expose 
freely the inferior portion of the tumour. It was found to consist of a fibrous 
and cartilaginous texture, with an extensive deposit of bone within it, which 
appeared to be articulated with the more deeply seated portion. Superiorly, 
the tumour presented in the interval between the tensor of the fascia and the 
m. sartorius, its base being packed as it were against the crest of the ilium. 
The bulk of the tumour was located in the m. rectus, and muscular fibres 
radiated from all portions of it. After enucleating the tumour by dissection 
in order to reach its attachment, it was necessary to divide partially the ten- 
dons of all these muscles. The anterior portion of the capsular ligament was 
found completely involved in the diseased mass, and a pedunculated bony con- 
nection existed at the margin of the acetabulum, external to the short head 
of the m. rectus, and which was separated with some difficulty. The cavity 



1858.] 



Sawyer, Osteoid Growth at Right Hip-joint. 



113 



of the joint presented a remarkable condition. The acetabulum was very 
much enlarged, and rather flattened by the absorption of old and the deposit 
of new bone. The round ligament had disappeared. The head of the femur 
was rough and flattened, and not a trace remained of the articulating carti- 
lages. On dividing the bony attachment above referred to there was an escape 
of what appeared to be synovial fluid, perhaps Jss in amount, and of a healthy 
appearance ; but not a trace of synovial fluid or pus existed in the cavity of 
the joint. From its pathological condition we might justly have expected an 
abundance of the latter; but the opposite character rather existed — a peculiar 
dryness of the articulation which we are at a loss to account for. 

There was not much hemorrhage during the dissection. Two large branches 
of the profunda femoris directly supplying the tumour required ligature; 
otherwise a few superficial vessels only. 

Doubts still existing as to the malignancy of the tumour, and as the wound, 
although severe, appeared clean, with no traces of the tumour remaining, and 
as it was thought, notwithstanding the cavity of the joint had necessarily 
been opened into, that its altered relations would protect it from the severe 
results usually to be apprehended from wounds of healthy articulations, it 
was deemed expedient, on consultation, to attempt to preserve the limb. The 
edges of the wound were brought together with sutures, cold-water dressings 
applied, and stimulants allowed according to the will of the patient. 

Dissection of the Tum,our. — The 
tumour was seven inches in length, of Fl g- 
a lobulated form, gradually tapering 
towards a slender bifurcated extremity; 
its surface was very irregular, and mark- 
ed with the attachment of muscular fibre, 
which soon became lost in the cartila- 
ginous matrix of the tumour. There 
were also radiating patches of condensed 
fibrous substance stretching out into the 
surrounding muscle. There was no 
cyst-wall or a semblance of the partially 
distinct en'velop formed of the hyper- 
trophied areolar tissue often observed 
partly or entirely surrounding fibro- 
plastic tumours. It was composed of 
distinct masses of bone connected with 
each other and surrounded by con- 
densed tissue like fibro-cartilage. They 
appeared to result from special cen- 
tres of ossification, which would have 
eventually coalesced into a solid tumour. 




114 Sawyer, Osteoid Grovjth at Right Hip-joint. [Jan. 

As it was, the union being incomplete between the separate pieces permitted 
a latitude of motion in them to such an extent as to convey the idea of a' 
movable tumour in the examination previous to the dissection. The largest 
of the fragments was five inches in length by two in breadth, somewhat re- 
sembling a long bone in appearance, with an extremely dense exterior, and 
with its central medullary cavity, although very irregularly developed. The 
smaller pieces could be easily cut with a knife and had more the appearance 
of the cancellated texture of bone. The fibrous matrix in which they were 
formed was quite firm in texture, and distributed through it were numerous 
cells varying from the size of a bean downward, containing a peculiar curdy 
substance of a yellowish colour. These cells were also quite abundant in the 
parts ossified, and had firm walls of a fibrous character. Bands of white lus- 
trous fibre traversed the smaller ossified pieces without preserving any uniform 
direction. The portion of the tumour covering in the hip-joint had a rough 
villous surface; no trace of the synovial membrane could be found. The 
tumour was very vascular, the more solid parts being highly injected with 
bloodvessels resembling bone in an inflamed state. 

The microscopical appearances of the tumour are worth noting. Its matrix 
was composed for the most part of condensed filamentous tissue. The wavy 
fibres of a pearly lustre were clearly brought out in any section of what ap- 
peared to constitute the cartilaginous portion of the growth. The indurated 
nodules cropping out from the surface of the growth and imbedded in the 

surrounding muscle, evidently nuclei for 
the additional deposit of bone as the tumour 
increased in size, were purely made up of 
this texture. Interspersed among the meshes 
of the filaments was found an amorphous 
granular matter, an abundance of oil glob- 
ules, and cells containing nuclei and nucleoli 
such as are represented in Fig. 2. The 
ossified portions had the structure of true 
bone. The corpuscles of Purkinje with 
the radiating canaliculi were beautifully dis- 
tinct. An abundance of nutritive canals 
(corresponding to the canals of Haver) were 
observed, although irregularly distributed and soon lost in the surrounding 
fibrous tissue. 

The cysts previously described, found in the bone and the less solid parts of 
the tumour, contained an abundance of oil globules, granular matter, and the 
cell growth as seen in the accompanying drawing. 

As the result of our observations in this case we suspect that the areolar or 
filamentous texture is really that which in its modifications from a healthy con- 
dition, growing out of obscure, perhaps impenetrable causes, gives origin and 
material of progress, more frequently than is ordinarily supposed, to a large class 



Fig. 2. 




1858.] 



Sawyer, Osteoid Growth at Right Hip-joint. 



115 



of factitious growths which are engrafted on the human body. One of the most 
rudimentary forms of abnormal ossific structure is found in the subserous fila- 
mentous texture of arteries, where we have under the microscope simply an 
amorphous granular deposit. There is still a tendency towards a structure 
exhibited here, as the plates are arranged with a tolerably uniform thickness, 
preserving the calibre of the vessel. The modelling process by which this is 
accomplished belongs to the subserous tissue, and at all events shows an effort 
at arrangement not apparent in the masses of granular calcareous particles, 
loosely connected by fibrin, much resembling a precipitate from the blood, 
as we have seen in one instance, nearly obliterating the cavity of the aorta, 
the walls of which were almost completely transformed into a bony tube. In 
this case the ossific plates were found very numerously distributed in the coats 
of the larger veins. 

That the filamentous tissue may possibly form the nidus for the extension 
of morbid growths, when their nutrition becomes active, derives some support 
from the wide-spread anatomical relations of this texture to the organic fabric. 

The curious attachment of muscular fibre to the surface of these tumours 
is thus easily accounted for. As the tumour grows, the sheaths of successive 
fasciculi being gradually incorporated with it, making for them new and inde- 
pendent attachments, we believe the muscular fibre to be gradually lost by 
the absorption of its elements, and not transformed into the proper texture of 
the tumour. Tn the case of osteo sarcoma of the tibia, already cited, the 
principal mass of the disease posteriorly corresponded directly in outline with 
the m. popliteus, a few shreds of this muscle only remaining superficially. 

The various forms of abnormal structure of which the etiology is so little 
understood, may well be regarded as the genuine parasites of the human body, 
corresponding approximative^ to the fungi of the vegetable world. All pa- 
thologists agree in considering them as textures of a low vital type, and were 
it reasonable to draw conclusions from a single case, we should assert that the 
more primitive structures in the animal body afforded the most natural habitat 
for their development, as the lowest forms of vegetation, to pursue our analogy, 
connect themselves with the least vitalized portion, as the bark of the higher 
orders of plants. 

These reflections are simply suggestive, to provoke inquiry, rather than to 
intrude on the profession dogmatical statements. 

In the evening after the operation, reaction was well established, and the 
patient made no complaint. Pulse 100, full and soft. Opiates were allowed 
to promote rest. 

22d. The patient rested tolerably well during the night. The tongue con- 
tinued moist, although there was some thirst. Pulse 110. Some pain in the 
wound, not severe enough to occasion distress, with slight tumefaction. 

Strongly nutritive drinks allowed ; anodynes continued, with moderate use 
of stimulants. 

23d. Eeported himself as more comfortable. Slept well during the last half 
of the night. The bowels have not been moved since the operation. Pulse 



116 Sawyer, Osteoid Growth at Right Hip-joint. [Jan. 

116, rather sharp. The thigh is somewhat swollen; the margins of the 
wound reddened, with a considerable discharge of sanies. 

A full nutritive diet ordered. Castor oil to act on the bowels. 

24/A. Irritative fever, with marked constitutional prostration. Two dejec- 
tions from midday of yesterday. Sharp pains complained of through the lower 
portion of the abdomen. Wound as previously described. Pulse 127, sharp. 

Stimulants and opiates continued, with warm fomentations over the abdo- 
men, and a light yeast poultice to envelop the thigh. 

7 P. M. The patient was suffering the most agonizing pains, with a sense 
of tightness and constriction through the lower portion of the abdomen. No 
additional tumefaction or irritability about the wound. Discharge scanty, of 
a sero-purulent character. A greenish discoloration over the m. glutei ob- 
served stretching across the lumbar region of the back. The pulse can 
scarcely be counted. 

25th. Well-marked gangrene established in the parts mentioned in the 
previous report. The patient finally sank after extreme exhaustion. 

Autopsy 12 hours after death. — Slight cadaveric rigidity. The discolora- 
tion of the integument was confined to the lower back and buttocks, without 
any tendency to a line of demarcation, and not involving either the wound or 
the thigh. The muscular textures were generally much softened, including 
the muscles of the thigh, otherwise but little change had taken place in the 
track of the wound. About 3 ij of sanious pus, without marked fetor, was 
found in the cavity of the joint. No traces of excited action existed in the 
joint itself, or textures immediately adjoining. No traces of inflammation of 
either the veins or arteries could be discovered. Viscera of the chest and 
abdomen perfectly healthy. 

We have added a drawing of the pelvis and head of the femur, showing the 
condition of the bone entering into the hip articulation (see Fig. 3). The gross 



Fig. 3. 



1858.] 



Storer, Cupping the Interior of the Uterus. 



117 



appearances will immediately strike one as similar to the changes often observed 
in coxalgia, and were accomplished by the progressive absorption of old bone 
and the deposit of new ossific material. There were no evidences of caries or 
necrosis. Absorption was more active than the reparative process, as the new 
deposits seen about the margin of the acetabulum and the head of the femur 
were of a light porous character, it being possible to compress many of the 
little nodules between the thumb and forefinger. External to the acetabulum, 
although the form of the pelvis had been preserved, the bone had become so 
thinned and porous by absorption, as to admit rays of light to readily pass 
through the minute intervals from one surface to the other. The neck of the 
femur appears, at first sight, shortened. On comparison with its fellow this 
was found not to be the case. The head of the femur was flattened and 
fissured, its margins irregular and expanded by the deposition of new material. 

The cause of gangrene in this case was a little obscure. It will be observed 
that it did not display itself in the parts where we should have more naturally 
expected, either in the wound itself or the thigh, but in the back and gluteal 
region. It could not have resulted from loss of blood, for the hemorrhage 
during the operation was trifling, the two large branches of the profunda 
being ligated as soon as divided. 

It is more probable that death resulted from the prostration of the nervous 
centres connected with the operation, although this is diflicult to concede, for 
the patient was remarkably comfortable, considering the severity of the case, 
up to the day preceding his death. 



Art. VIII. — Cupping the Interior of the Uterus. By Horatio R. Storer, 
M. D. (Read before the Boston Society for Medical Observation, Oct. 19, 
1857.) 

Case I. — Catharine , of Roxbury, aged thirty, and unmarried, applied 

for treatment at the Eustis Street Dispensary, February 2, 1857. 

Catamenia reported as entirely absent for seventeen years ) having com- 
menced at twelve, continued regular for one year, and then on her taking 
cold, permanently ceased. A general leprous eruption, which immediately 
followed this suppression, has been constantly present since, disfiguring the 
patient and otherwise causing her much discomfort. 

Somewhat dyspeptic and anaemic ; costiveness ; addicted to headache, flatu- 
lence, nausea. Old ulceration of tonsils. Vaginal leucorrhcea. 

She was at first mainly treated for the disease of the skin. The diet was 
carefully regulated and the bowels kept moderately open. Iodide of sulphur 
was used locally, Fowler's solution by mouth till specific effect; in vain. 

The protoiodide of mercury was then given, though all syphilitic taint had 
been denied. It was pushed till great irritability of the bowels was produced, 
though it had been combined with an opiate ; patient not improved. The 



118 



Storer, Cupping the Interior of the Uterus. 



[Jan. 



mercurial was subsequently resumed and continued till April 1, when the 
gums were sore. It was then stopped, and the arsenic again commenced. • 

In the mean time, the catamenial disturbance had not been lost sight of. 
There was never present any decided menstrual molimen; it was therefore 
impossible, save empirically, to time the attempts at assisting nature. Ther<? 
was, it is true, pain in the head and back, but irregular and uncertain, while 
the leucorrhoea presented no monthly or periodic increase. 

On March 14, alteratives and tonics having been given for six weeks, with 
aloetic purgatives, hot hip-baths, &c. &c, from time to time, without benefit 
either to skin or uterine system, a vaginal examination was made. The 
abdomen had been previously ascertained to be free from enlargement or 
tenderness. The uterus was found depressed and slightly retroverted ; its 
cervix elongated, but of small diameter; os almost impervious. The sound 
entered with difficulty about two inches. 

Sinapisms to the breasts were now ordered, in addition to and with the 
emmenagogues already employed. 

March 19. No effect produced, other than that patient has so well tested 
the mustard as to have blistered both breasts. These abrasions were treated 
by collodion. 

April 1. A succession of flexible metallic bougies, an eighth to a fourth of 
an inch in diameter, were passed through the cervix uteri. 

4th. A galvanic stem-pessary, an eighth of an inch in diameter, introduced 
into the cavity of the uterus. 

12th. Pessary still worn. Patient cupped at and below sacrum. 

May 8. No effect having been produced, the intra-uterine air-pump here- 
after to be described was applied, and by it £ss of blood drawn from the in- 
terior of the uterus. This was early in the morning ; the discharge continued 
throughout that day and night. 

June 6. Patient reports herself as in all respects better. Air-pump again 
applied, and flow again produced ; this time more readily than at first. 

When last seen, early in July, the patient had still further improved in 
general health and spirits, while her skin had begun to assume a more natural 
hue and feel. 

In this woman the cutaneous affection not merely accompanied, but was 
apparently consequent upon the suppression of the catamenia. Such being 
the case, its obstinacy, equal in intensity and duration to that of the original 
disturbance, is explained. 

In the treatment of the case, from the outset, I was aided by my friend 
Dr. Hayward, of Eoxbury. 

Case II. — Margaret , aged twenty-five, from Winchester, entered the 

Lying-in Hospital, under my charge, October 10, 1856. 

Patient unmarried. Catamenia never appeared till her twenty-first year ; 
discharge always very scanty, ceasing and reappearing at intervals during one 
or two days, and always attended with excessive local pain, which continued 
throughout the period. Recurrence of menses irregular, frequently passing 
five or six weeks, as is at present the case. 

Dyspeptic, anaemic, hysterical; for which general treatment, hydrocyanic 
acid, cannabis indica, &c. &c. 

Upon examination, some tenderness of abdomen, which was retracted. To 
the touch, the os seemed almost impervious; cervix somewhat elongated; 



1858.] 



Storer, Cupping the Interior of the Uterus. 



119 



uterus depressed. For this a ring pessary had formerly been introduced, 
with some relief. Ordered aloes, hot hip-bath, sinapisms to breasts. 

October 12. No appearance of menses. Uterine sound introduced two 
inches, and followed by smallest sized galvanic stem-pessary. 

The next morning the menstrual discharge was established, not very abund- 
antly, but comparatively more so than ever before, and with very much less 
pain. It continued for two days. 

22d. To-day a series of four metallic bougies passed ; all, even the largest, 
with ease. 

November 15. Bougies repeated. Yesterday and the day previous, galvanic 
pessary. To-day menstruates as before, and almost without pain. 

The flow continued two days; and then, on November 17, patient discharged 
from the hospital, much relieved. 

In the spring of the present year, I was again consulted by this patient 
The improvement above noted had continued for some time, and had then 
yielded to a recurrence of all the former distress. I therefore applied the 
air pump, the menses being overdue, and produced a free sanguineous dis- 
charge. This was several times repeated, at the proper intervals, in July for 
the last time, always with relief to the usual symptoms, and apparently with 
permanent benefit to the general health. 

The cases reported were instances of amenorrhoea — the one partial, the 
other total ; and in both organic, for in both the uterus was found undersized 
and undeveloped. In neither, however, was there any obstacle to the flow 
had free excretion from the uterine tissue existed, for though the os in both 
cases was extremely small, yet in neither did it offer any decided resistance 
to the passage of bougie or uterine sound. In one the catamenia had appeared 
very early, in the other very late. In one the suppression had been almost 
immediate and total; in the other incomplete, but constant and accompanied 
by intense dysmenorrhoea, apparently not obstructive as ordinarily defined, 
but congestive in its character. They may each require an extension of the 
treatment, but its immediate and decided effect for good, both on the uterine 
system and general health, give hope that the improvement may prove per- 
manent. 

It will be noticed that the remedies most frequent or most powerful had 
been faithfully but vainly tried. The fact that I avoided others that might 
be mentioned, ergot, galvanism, vaginal leeching, and the like, was in part 
owing to experience of their inefficacy, and in part to desire for testing the 
mode of treatment now described. 

The operation, bold as it is novel, of producing hemorrhage from the uterus 
by actually cupping its internal walls, was conceived and apparently first 
practised by Prof. Simpson, of Edinburgh, and I am not aware that it has 
as yet, by himself or by another, been made public or described. It seems 
philosophically based, and the only questions to be settled are those of its 
safety and success. To these, answers in part at least are found in the cases 
now reported, whose progress, communicated to them at the time, has already 
afforded matter of interest to several members of the profession. 

The instrument used, identical save in coupling, with one made for me at 



120 



Atlee, Rupture of the Trachea. 



[Jan. 



Edinburgh, in 1854, and now also exhibited, is from the hands of Messrs. 
Codnian & Co., of Tremont Street. 

Its construction is sufficiently simple. An air-pump, small but powerful, 
and a perforated tube, itself of sufficient calibre to contain several drachms of 
blood, yet not too large to enter the os and cervix uteri; its orifices of a size 
to escape easy clogging with mucus or clots of blood, and yet too small for 
extensive laceration or hernia of the mucous coat, and its axis curved to 
correspond with those of the uterus and vagina. Its passing to a sufficient 
depth within the uterine cavity is insured, its entering too far is prevented, by 
a ring of gutta percha, bevelled above for more perfect closure of the os, and 
adaptable to any case by remoulding. The exact position of this ring is to be 
determined by previous careful use of the uterine sound. Like that of the 
intra-uterine pessary, the point of the stem should almost, but not quite, reach 
the fundus uteri. By this precaution danger is avoided, and a much more 
thorough effect rendered probable. 

To the manner of coupling l am inclined to attach some importance. In 
the Edinburgh instrument, the pump is screwed to the upper portion of the 
lower tube, while in the other I have joined them by caoutchouc pipe. The 
liability of a screw-thread to become worn, and the less chance of violence in 
case the piston should play stiffly, if the coupling, while perfectly tight and 
fitting, were yet elastic and flexible, occasioned this modification. 

I have used the cup in other cases than those reported, in every instance 
with the effect of inducing the sanguineous discharge, and I have never seen 
from it any permanently disagreeable result. Its power upon the nervous 
system is, however, at times so decided that its use should be with care. In 
one case, where the introduction of the instrument had been painless, the first 
play of the piston occasioned instant and alarmingly profound syncope. 

To the microscopist, this instrument might frequently prove of use, by 
affording an easy means of procuring healthy or diseased secretions directly 
from the cavity of the uterus. 

Whether in practice the cup will be found to answer any other indication 
than that for amenorrhoea already instanced, as for relieving ordinary con- 
gestive and inflammatory attacks, either of the uterus itself, Fallopian tubes, 
or ovaries, remains yet to be seen. 



Art. IX. — Rupture of the Trachea, from a fall. Communicated by John 
L. Atlee, Jr., M. D., of Lancaster, Pa. 

On the 22d of July, 1856, a boy, four years of age, the son of J. W., a 
resident of Lancaster, in running across the street, tripped at the curb-stone 
and fell, striking his neck with force against the scraper at the side of the 



1858.] 



Atlee, Rupture of the Trachea. 



121 



door of his father's house. The blow caused for a few moments extreme 
difficulty of breathing, and I was at once sent for. 

I reached the house not more than five minutes after the injury had been 
received, and the child was then seated upon his mother's lap, his head rest- 
ing against her arm, and breathing naturally, or very nearly so ) there was 
some blueness of the lip, but this soon passed on ; on his countenance there 
was not much appearance of distress. Where the neck had come in violent 
contact with the scraper, there was not the slightest mark upon the skin. I 
was just about to congratulate the family upon the slightness of the injury, 
when the child, struggling to free himself from his mother's arms, threw 
himself violently backwards. He at once became enormously swollen, and 
in a moment was dead. The cause of the swelling was evidently the entrance 
of air into the cellular tissue, and it extended over the head, the neck, the 
trunk, and the upper extremities to the ends of the fingers. At the sternum 
the finger, before reaching the bone, penetrated fully an inch. 

To my extreme regret, a post-mortem examination was refused. My 
opinion of the case was this : That when the neck had struck the scraper, the 
rings of the trachea had been separated from one another, but that they had 
remained in place until dislocated by the act of throwing the head back- 
wards ; when this occurred, the air contained in the lungs was forced vio- 
lently into the cellular tissue of the body. The difficult breathing imme- 
diately after the accident, must have been caused by spasm of the glottis, 
produced by the direct blow, as we sometimes observe after severe blows of 
the fist. 

In wounds of the air- passages, all works on surgery warn us against im- 
proper bandaging of the external wound, on account of the danger of emphy- 
sema, but no notice is made of an injury similar to the one I have just 
related, except in the work of Ryland. 1 There is also a case reported in the 
Lancet for the 6th of September, 1856, by Dr. Robertson, resident English 
Physician of the Baths of Wisbaden, who styles it an " unique casualty/' 
These cases have never been published in this country, and as they are very 
extraordinary, and as, moreover, from the autopsies, they enable us to explain 
the phenomena observed in the case I report, it may be well to give them. 

Ryland, at page 250, says : — 

■ 

Wounds of the larynx may prove fatal by causing emphysema of the 
body to such an extent as to impede respiration, but this must always be 
owing to a faulty or inattentive mode of dressing or bandaging the wound, or 
to the injudicious use of sutures. If, however, the larynx be crushed or 
ruptured without the skin giving way, emphysema is a certain result, and if 
it be not actively treated, may destroy the life of the patient. The only 
instance of this kind of injury that I have met with, is a case by Dr. O'Brien, 
in the Edinburgh Medical and Surgical Journal, vol. xviii. 

1 Treatise on the Diseases and Injuries of the Larynx and Trachea, by F. Ryland, 
London, 1837. 



122 



Atlee, Rupture of the Trachea. 



[Jan. 



u A woman was brought into the Royal Infirmary of Edinburgh, on the 
evening of the 23d of July, 1818. The face was tumid, lips livid, breathing 
very laborious and stridulous. The skin was cold, and that of the thorax, 
neck, face, and superior extremities, distinctly emphysematous; and the pulse 
was scarcely perceptible. She pointed to the throat as the chief seat of pain, 
and said she had been kicked under the jaw; on the lower anterior part of 
the neck was a bluish mark. Scarification^ were made about the lower part 
of the neck, and restoratives and opiates were administered internally. On 
the following morning her breathing had become more difficult, and she ex- 
pired about nine o'clock. 

"Dissection. — The cellular substance of the neck was everywhere distended 
with air. On the soft parts being removed, a rupture was found through the 
whole depth of the thyroid and cricoid cartilages, on the left of their mesial 
line, and then through the right side of the first ring of the trachea. The 
ruptured edges of the cartilages were rather tumefied, and slightly inverted. 
Most of the cellular substance surrounding the larynx, pharynx, and trachea 
was emphysematous. The anterior mediastinum was also emphysematous. 
On opening the heart, the blood was found not coagulable, and quite frothy 
from the admixture of air, and that in the aorta and vena cava abdominalis 
was in the same state." 

In the case reported by Dr. Robertson, in the Lancet, and which is an ab- 
stract of the report of Dr. Berger, the Surgeon-General, the injury, as will be 
seen, did not affect the larynx at all. 

" Cannonier B , of the Artillery of the Prussian Guard, was kicked by 

a horse a little below the lower jaw, while engaged in washing his hind hoof. 
A small unimportant skin wound exhibited itself at the edge of the jaw, and 
some blood, but not much, flowed from the mouth. The neck, however, 
rapidly swelled to an extent sufficient to materially impede respiration. The 
patient complained only of a peculiar sensation of weight at the epigastrium, 
and stated that he felt as if blood had collected in his windpipe, and pre- 
vented his breathing freely. There was no fracture or injury to be discovered 
in the larynx. The patient was at once bled ; generally from the arm, and 
locally by leeches, without the slightest effect upon the orthopncea.' The 
latter symptom continued to increase rapidly until so fearful an emphysema 
had established itself that the chest, neck, and face of the man were swollen 
to a frightful extent ; and in this state, suffering great agony, he died within 
an hour and a half of the receipt of the injury. 

" The post-mortem examination discovered a complete rupture of the trachea 
from the larynx, the latter being uninjured. The separation commenced at 
the left side of the cricoid cartilage, proceeding to the right as far as the mid- 
dle of the posterior edge, so that a third part only of the union of the trachea 
and larynx remained intact. Several of the cartilaginous rings and ligaments 
of the trachea were ruptured, and it was found filled with coagulated blood. 
The thyroid, cricoid, and arytenoid cartilages were quite uninjured. The 
heart was in a normal condition ; the lungs were congested, and of an unu- 
sually dark colour/' 

In connection with the above mentioned cases of general emphysema from 
external injury, it may be interesting to know that in the Gazette Medicate 
for 1840, p. 698, a case is recorded in which it resulted from the perforation, 
by ulceration, of the right ventricle of the larynx, a little below the vocal 



1858.] 



Harris, Case of Fallopian Pregnancy. 



123 



chord. The patient was a young girl, fifteen years of age, who had been 
attacked with ulcerative pharyngitis and laryngitis. 

In cases of this kind, when their true nature is at once ascertained, it would 
certainly be advisable to resort immediately to tracheotomy. It is true that 
the ultimate cure of the patient is very doubtful, but it would afford a rea- 
sonable chance of at least prolonging life. 



Art. X. — Case of Fallopian Pregnancy resulting in Rupture of the Cyst and 
terminating in Death. Reported by Robert P. Harris, M. D., Phila- 
delphia. [Read before the Philadelphia Pathological Society Nov. 25th, 
1857.] 

Mrs. S., the subject of the following report and observations, a lady of 
medium height, somewhat full habit, 27 years of age, and the mother of an 
infant a year old, ate her breakfast on the morning of the 24th of October, 
1857, apparently in perfect health, and between nine and ten o'clock was 
suddenly seized with excruciating pain in the lower part of the abdomen, 
followed almost immediately by a feeling of faintness. Her pulse became 
very rapid and feeble, extremities cold, and surface of the body very pale, as 
though exhaustion was being produced by internal hemorrhage. Stimulants, 
such as wine whey, brandy and water, milk punch, and carbonate of ammo- 
nia were freely administered, and cataplasms of mustard and ginger, together 
with frictions of Cayenne pepper and whiskey applied externally, but to no 
purpose. The pain, which was at first very severe, snon diminished, and 
finally ceased; she gradually became more and more feeble, no pulsation of 
the arteries at the wrist was perceptible, and the whole surface of the body 
became cold, so that in a few hours from the commencement of the attack 
all hope of recovery was abandoned. She remained in a moribund condition, 
with little apparent change, until, from a gradual loss of vital power, she 
ceased to breathe about seven o'clock on the following morning, twenty-one 
hours after the commencement of the attack. 

The next great point of interest in the case was to find out the cause of 
death, for although a correct diagnosis was not impossible, yet its uncertainty 
demanded that, for the benefit of science, it should be verified by the only 
sure test in such cases, i. e. a post-mortem examination of the body. By a 
refusal to grant a certificate of death to the relatives of the deceased because 
of incompetency to state positively the cause of death, permission, after some 
hesitation, was obtained to make an autopsy, and twenty-nine hours after 
death we entered upon the examination. Upon uncovering, the body, the 
abdomen was found much distended and tympanitic over its whole extent, 
and, incising the skin and soft parts down to the linea alba, a thickness of 
adipose deposit, varying from an inch to an inch and a half, proved the full 
state of health of the patient at the onset of her disease. Further dissection 
showed that the intestines, both large and small, were very much inflated, and 
that the omentum was wrinkled and drawn up to the right upper portion of 
the umbilical region. Extending the vertical incision down to the pubis, we 
were arrested in our examination by the escape of a small quantity of serous 



124 Harris, Case of Fallopian Pregnancy. [Jan. 



fluid, and upon drawing the intestines upward from the brim of the pelvis, 
we found that the cavity of the pelvis, as well as the lower and back part of 
the abdominal cavity, was filled with black blood in a partly fluid, partly 
coagulated state. After this was removed by means of a sponge, to the amount 
of perhaps half a gallon, a small abnormal growth in the course of the right 
Fallopian tube arrested our attention, and caused us to dissect out and care- 
fully remove the uterus with its appendages. 

The uterus proved to be scarcely if at all enlarged beyond the size we 
usually find it in healthy women who have borne children. Its cavity con- 
tained a little mucus slightly tinged with blood, but no trace of a membrana 
decidua; the ovaries were healthy, of normal size, but very pale in colour, 
from their anaemic state, and the left Fallopian tube presented nothing unu- 
sual; but in the right one, immediately above the ovary, was a tumour of an 
oval form, slightly flattened antero-posteriorly, about an inch and a quarter 
long, an inch in its vertical diameter, and of a reddish-blue colour. Upon 
close examination, a small opening of a little more than a line in diameter 
was detected at its upper surface, perforating the edge of the broad ligament. 
This hole communicated with the peripheral portion of the body, but not 
with its interior cavity. An incision made through the cortical portion so 
as to divide the body to its centre, revealed a cavity containing a small dia- 
phanous sac, within which was a human embryo of a pure white colour, and 
half an inch in length, looking a good deal like a common maggot. 

Here, then, was clearly revealed the cause of death, and the supposition 
with regard to the nature of the disease proved to be correct. An ovum had 
become arrested in the Fallopian tube in its progress from the ovary to the 
uterus, had become partly developed in its abnormal situation, and when it 
had attained the age of three or four weeks had bursted, thereby making a 
direct communication between its bloodvessels and the cavity of the abdomen, 
and the patient had died of internal hemorrhage. This Fallopian or tubal 
cyst and the diameter of the perforation had in all probability been larger at 
the time that rupture took place than they were found to be when the au- 
topsy was made, as they would both naturally diminish somewhat after the 
force of the discharging current of blood began to decrease. This would 
account for the sudden prostration that took place at the commencement of 
the hemorrhage, as well as for the length of time that the patient lived after 
she appeared to be in a dying condition. The accident was no doubt in a 
great measure determined at the time it did take place, by the condition of 
the patient, who was menstruating. The increased flow of blood to the ute- 
rine organs probably contributed to produce the rupture of the cyst, which 
appeared to have given way very much after the manner of an aneurismal 
sac. The chief peculiarity of the case was the very early age in the deve- 
lopment of the ovum at which the rupture took place, a shorter time after 
conception than any of the cases of similar accident that I have met with in 
works upon extra-uterine pregnancy, or in the medical journals. 

Remarks. — In view of the importance of this interesting case, it will be 
perhaps profitable to examine more particularly into the nature of Fallopian 
pregnancies, the most common to be met with of all the forms of extra-ute- 
rine foetation. Embryologists whose researches have been most recently 
brought before the eye of the profession divide the forms of extra-uterine 
pregnancy into ten separate and distinct varieties, of which six are more or 
less connected with the Fallopian tube. These have been denominated sim 



1858.] 



Harris, Case of Fallopian Pregnancy. 



125 



pie Fallopian or tubal; tubo-ovarian ; tubo-abdominal; utero-tubal; tubo- 
uterine-interstitial, and utero-tubo-abdominal — names which in a very simple 
manner convey to the mind a knowledge of the situations occupied by the 
ovum. 

Causes of Fallopian Pregnancy. — When we look into the nature of con- 
ception, and the structure and uses of the Fallopian tube, we are not surprised 
that cases of tubal pregnancy are met with, but are amazed that they do not 
more frequently present themselves to our observation. M. Coste, of Paris, 
who has for the last twenty-six years been investigating the nature of con- 
ception and foetal development under the most favourable circumstances; M. 
Velpeau, and other celebrated embryologists, have not yet been able positively 
to determine the manner in which the ovule is carried from the ovary through 
the oviduct to the uterus. The spermatic fluid of the male, it is now gene- 
rally believed, passes along the Fallopian tube to the ovary and there fecun- 
dates the matured Graafian vesicle, which, bursting through the parenchyma 
of the ovarium, is grasped by the funnel-shaped extremity of the tube, to be 
carried into the uterus for its future development; but how it is so propelled, 
whether by a movement of the epithelial cilise of the mucous membrane lining 
the oviduct, by a consecutive annular dilatation and contraction of the walls 
of the tube, or by a combination of both species of movement, it is impos- 
sible fully to determine, though from the fact of the existence of longitudinal 
and circular muscular fibres in the walls of the tube it is most probable that 
progressive motion is given by them to the ovule, somewhat after the manner 
in which deglutition is effected in the oesophagus of a serpent. The canal is 
much too small in its natural condition to admit of the passage of the ovule 
without considerable dilatation, and, judging from the analogy which exists 
between the structure of the Fallopian tube and other tubular organs of our 
bodies whose propulsive power is much more readily and certainly determined, 
we have great reason for supposing that it is by a species of vermicular or 
peristaltic action that the Fallopian tube is enabled to perform one of its most 
important functions. It may be very readily conceived that the physiological 
action of the tube might by some disturbing cause of so slight a nature as not 
to be appreciable, be so deranged that an arrest in the progress of the fecun- 
dated ovule towards the cavity of the womb should take place, and the ovule 
be developed at the point where it ceased to advance. In some of the cases 
that have been reported by medical observers, injuries and severe mental dis- 
turbances were assigned as causes for this cessation of the conducting action 
of the tube; but in by far the greater number of those which have been pub- 
lished no definite reason could be given why the ovule should not have con- 
tinued in its onward movement until it reached the uterine cavity. In many 
of the autopsies that have taken place in cases where death has resulted from 
the bursting of a tubal fecundated cyst, the ovum had not advanced beyond 
the enlarged extremity or infundibulum of the oviduct, constituting the tubo- 
ovarian variety of extra-uterine pregnancy, in which situation the ovule is 
No. LXIX.— Jan. 1858. 9 



126 



Harris, Case of Fallopian Pregnancy. 



[Jan. 



probably arrested, from its being too largely developed previous to its passage 
into the funnel-shaped portion of the tube, to admit of its being carried 
through the more contracted section beyond. 

It is to be presumed that as there is no vascular sustenance afforded to the 
ovule until adhesion takes place between it and some contiguous tissue, that 
it does not increase in size in its passage from the ovarium to the uterus when 
no impediment to its course exists; which will account in a great measure for 
the infrequency of tubal pregnancies as compared with uterine. Simple tubal 
pregnancy is more common than any of the other six varieties, from the fact 
that as there is a long and narrow canal to be passed through, the ovule is 
here most likely to meet with impediments to its progress, or to form adhe- 
sions with the surrounding tissues; and cases are on record of the develop- 
ment of ova at almost any point between the infundibular portion and the 
uterine extremity of the tube, even in that portion of the canal which lies 
between the external and internal surfaces of the womb itself, where the 
passage is larger than the central section of the conduit. 

Diagnosis. — The difficulty of determining the presence of abnormal growths 
connected with the uterine appendages is well known to be very great; still 
more does it approach to an impossibility to define their nature when the fact 
of their existence is beyond dispute; and this is particularly the case in the 
early stage of their development, whilst they are but yet small. Some of the 
varieties of extra-uterine pregnancy can be distinguished with sufficient cer- 
tainty in the latter months of gestation to warrant a resort to an operation 
for the purpose of removing the foetus and thus favouring the cure of the 
patient. This is particularly the case with that form denominated sub-peri- 
toneo-pelvic, where the ovum is developed between the peritoneal laminae of 
the broad ligament, and which, as it increases in size, presents one extremity 
(generally that containing the head of the foetus) low down in the pelvis 
alongside of the vagina, where it may be felt and recognized: but in most 
tubal pregnancies the position of the sac not only renders it very difficult of 
recognition by palpation, percussion, or an examination per vaginam or rec- 
tum, but makes it almost impossible by such means to define positively to 
which of the varieties the disease properly belongs. When the foetus is suf- 
ficiently developed to afford recognizable cardiac sounds, the chances for mak- 
ing a diagnosis as to the true nature of the disease are much increased ; but 
we must not forget that here a mistake may be, as it has been made, for cases 
are upon record where intra-uterine foetation was mistaken for preternatural, 
and the sound of the arterial thrill in the aorta for that of the heart of a 
foetus. 

In those cases where a physician is called in to give his opinion as to the 
nature of the complaint, gestation is almost always advanced beyond the pe- 
riod when the patient this article refers to died, for in the first two or three 
months, as a general rule, the attention of the female is not directed to her 
condition by any symptoms sufficiently alarming to cause her to seek advice, 



1858.] Harris, Case of Fallopian Pregnancy. 127 

and she attributes her feelings to a natural condition consequent upon con- 
ception. If menstruation continues, which it does not do in the generality 
of cases, it will sometimes cause an earlier attention than otherwise; but not 
always so, as in many cases of normal gestation it is well known that women 
continue to be regular for a few months after conception has taken place. 
Ovarian pregnancy is much more apt to attract early attention than Fallopian, 
in consequence of the greater sensitiveness of the organ involved. Generally 
the first symptoms of an alarming kind which are felt are certain anomalous 
pains and spasms of the abdomen, accompanied by fainting turns and alarm- 
ing prostration. In tubal and ovarian pregnancies these pains are seated low 
down in the abdominal cavity, but in abdominal fcetation they are not much 
confined to one situation, but extend more or less over the whole abdomen, 
which is very tender to the pressure of the hand. These symptoms may be 
the immediate precursor of rupture of the sac, or they may disappear and 
return from time to time until either the foetus dies, the sac bursts, or some 
other of the changes to be hereafter mentioned take place in the sac or its 
contents. 

If the pains experienced are those of actual labour and the period of ges- 
tation be far advanced, there will be but little difficulty in telling whether the 
foetus is within or without the uterus. The abdomen will in the latter event 
be found of an irregular conformation and the foetus more to one side than 
ordinary. If the bladder be emptied by a catheter it will not be very diffi- 
cult to feel the fundus of the womb just above the symphysis pubis, as in 
cases of normal parturition after the expulsion of the foetus, and when the 
membrana decidua (if there be one) is expelled, to establish the non-existence 
of a foetus in the uterine cavity by the introduction of the index finger. 

The frequency of the existence of tubal pregnancy as compared with the 
other forms of extra-uterine foetation, makes it probable, when we meet with 
a case of preternatural gestation, that it belongs to the former class. The 
collection of cases made by M. Daynac, of Paris, and published in 1825, 
shows that in one hundred and fifty cases of extra-uterine pregnancy, about 
ninety, or three-fifths, belong to one or other of the tubal varieties; thirty, 
or one-fifth, to the ovarian, and the remainder to the abdominal, &c. Some 
writers have stated the proportion of Fallopian pregnancies to be still greater, 
as M. Czihak, who says that they are as three to one. In many cases of sim- 
ple Fallopian pregnancy during the early months of gestation, the uterus is 
little if at all augmented in size ) but in some, as the utero-tubal and utero- 
tubo-abdominal varieties, where the womb makes a portion of the gestative 
sac, it becomes considerably enlarged, thus deceiving the physician as to the 
nature of the pregnancy when examined by the touch. In the latter months 
of gestation the uterus is enlarged in all the varieties of extra-uterine preg- 
nancy, though much more in those immediately connected with it than those 
entirely separated from it. In order fully to comprehend the difficulties which 
stand in the way of making an accurate and reliable diagnosis in extra-uterine 



128 



Harris, Case of Fallopian Pregnancy. 



[Jan. 



pregnancies it is only necessary to refer to the reports of cases to be met with 
in medical books and periodicals and see the mistakes that have been made 
by men of undoubted skill. When a small ovum has bursted there is often 
less difficulty in determining the nature of the lesion than there is when the 
sac is whole, and of much larger size than the cyst found in the case of Mrs. 
S.; for although in the former case auscultation, palpation, and the touch are 
capable of revealing nothing, yet the alarming symptoms present indicate 
with some degree of probability the nature of the malady. 

In determining the nature of the disease which had caused the death of 
the patient whose case has been recorded in these lines, I reasoned, before 
commencing the examination of the body, in this way : Here is a lady of full 
habit whose health has for some months been excellent, and the age of whose 
infant makes it highly probable that she may have conceived. The symp- 
toms of her malady evidently denote that she died from the effects of internal 
hemorrhage, and the manner of the commencement of the attack, that the 
blood escaped into the cavity of the abdomen. Now where did this blood 
come from? The patient, before her last accouchement and for some time 
subsequently was troubled with diarrhoea : might she not have had perforation 
of the intestines? The physical condition of the woman, and her excellent 
health for some months past show almost to a certainty that no ulceration 
sufficient to have produced such an event could have existed in the alimentary 
canal. Was she pregnant? She thought not, because she was menstruating 
when the attack came on : but this does not prove the non-existence of extra- 
uterine pregnancy, as many cases which have been recorded show that the 
menstrual function is frequently not affected by preternatural pregnancies. 
The os uteri when examined by the touch soon after the commencement of 
the attack, appeared to be very sensitive, which is often the case in disease of 
the uterine appendages, but it is no positive indication of the existence of any 
lesion, because menstruation of itself sometimes increases the nervous sensi- 
bility of the uterus. The nature of the pain experienced, its seat at the lower 
part of the abdomen, and the evidence of a sudden and continued discharge 
of blood, commencing directly after the pain was first felt, so exactly corre- 
sponded with the history of many recorded cases of rupture of extra-uterine 
cysts that I was led to believe that a post-mortem examination would prove 
that I was correct in pronouncing the cause of death to have been the "rup- 
ture of an extra-uterine fecundated cyst." Having determined in my mind 
the nature of the disease, it was of little practical moment where the cyst was 
situated in a case of this character; from the frequency of Fallopian preg- 
nancies over the other varieties of preternatural foetation, it would have been 
natural to have supposed that the seat of the cyst would be found to be some 
portion of the oviduct. 

Prognosis. — From the nature of Fallopian pregnancies it will readily be 
conceived that the prognosis is exceedingly unfavourable, an opinion which 
will be fully confirmed by a reference to reports of published cases to be found 



1858.] 



Harris, Case of Fallopian Pregnancy. 



129 



in the collections of Dezeimeris, Petsch, Moreau, Daynac and others. Al- 
though Fallopian gestation is not in all its varieties necessarily fatal, yet the 
great majority of cases ultimately sooner or later perish, and most of these 
from internal hemorrhage. The length of time that elapses between concep- 
tion and a fatal termination varies very much in different subjects, being de- 
termined in some cases by accidental causes, as blows, falls, &c, and in others 
by distension and thinning of the walls of the sac; by mechanical pressure; 
uterine gestation; hyperemia of the uterine vessels; conversion of the cyst 
into a dropsical sac; suppuration, &c. Most of the cases of rupture terminate 
before the fifth month, but some do not until the full period of gestation is 
completed. The bursting of the tube is not in all cases followed immediately 
by death, for in some the ovule escapes entire, falls into the abdominal cavity, 
and there forms adhesions, becoming further developed as an abdominal preg- 
nancy; in others the placenta remains attached within the tube, and the 
membranous bag containing the foetus escapes to become thereafter developed 
exterior to the tube in the abdominal cavity, constituting a tubo-abdominal 
pregnancy. In the first case a cure may possibly take place by ulceration, so 
as to discharge the foetus into the rectum or vagina, or be effected artificially 
by the vaginal section ; in the latter, gastrotomy might possibly be performed 
with benefit, but I am not aware of its ever having yet been attended with 
other than fatal results so far as the effect upon the mother is concerned, owing 
to the difficulty of removing the placenta without fatal consequences, the 
impossibility of letting it remain and still saving the patient, and the danger 
of peritonitis. A very interesting example of abdominal pregnancy in which 
gastrotomy was performed may be found recorded in the Philadelphia Journal 
of the Medical and Physical Sciences, vol. i., New Series, 1825, p. 129. The 
patient died of peritonitis upon the fifth day after the operation. 

Of the six varieties of extra-uterine foetation in which the Fallopian tube 
forms the whole or contributes to form a part of the gestating sac, the utero- 
tubal is the most favourable. In this form it is quite possible that the efforts 
of nature alone, or if not, with the assistance of the hand of an accoucheur, 
may suffice to deliver the woman through the natural outlet, for a proof of 
which I refer you to the case reported by Bichter and reprinted in Moreau' s 
work upon extra-uterine pregnancies, 1 and to that reported by M. de Ritzen, 
reprinted in the Medical Examiner (Philadelphia) of 1841, p. 638. The 
favourable results of these two cases must not always or even generally be 
expected in utero-tubal pregnancies, for it is this variety which by consecutive 
action forms the utero-tubo-abdominal, perhaps of all the forms the most cer- 
tain to result in the death of the patient. In the work of Moreau above 
referred to (pp. 29 to 36), may be found three very interesting reports of 
cases of this latter complicated preternatural pregnancy, which were observed 
and described by Patuna, William Hey, and Hoffmeister, the last of whom 



1 Des Grossesses Extra-Uterine, par M. Alexis Moreau, p. 27. Paris, 1853. 



130 



Harris, Case of Fallopian Pregnancy. 



[Jan. 



performed the operation of gastrotomy upon his patient immediately after her 
death, in the hope of saving the life of the foetus, but without effect. 

It is not necessary to the favourable termination of all cases of Fallopian 
pregnancy that the contents of the gestating sac should be removed from the 
body either by the efforts of nature or by a surgical operation, for there is 
quite a number of cases on record whose recovery took place with the foetus 
remaining in situ. Owing to some cause or other not to be readily accounted 
for, the foetus sometimes ceases to grow, and loses its independent life without 
being, properly speaking, dead, as it still remains an organized body, capable 
of undergoing many of the changes to which such bodies are subject. From 
published researches we learn that the following remarkable changes have 
been observed to take place in the sac and its contents : Most commonly the 
cyst has been found contracted, the liquor amnii in whole or a great measure 
absorbed, and the foetus shrivelled, as though it had undergone a species of 
mummification. In other cases the sac has been found changed to a cartila- 
ginous substance, or converted partially or entirely into bone; and the foetus 
into bone wholly or partially, or changed into a cretaceous substance, or into 
a mass resembling adipocire. In Cloquet's Pathological Anatomy may be 
seen a fine view and section of a cretaceous or petrified foetus. This trans- 
formation is rare in tubal pregnancies, nevertheless it does occur; in proof of 
which see the report of a case by Fritze, of Strasbourg, in 17 79, and referred 
to in the works of Moreau and others. In abdominal pregnancies it is of 
more frequent occurrence. After the transformations mentioned foetuses have 
been carried in the abdomen with little or no inconvenience for a number of 
years, reaching as high as fifty-four in one case on record. M. Majon disco- 
vered an ossified foetus in a female who had died at the age of 78 years, and 
MM. Varnier and Mangin found two in a woman of 74, one of which was 
ossified and the other entirely decomposed, with the exception of the bones. 

Treatment. — Fallopian pregnancy as well as the other forms of extra-uterine 
foetation are to be regarded more in the light of curiosities than of diseases 
which are amenable to treatment, though under certain circumstances much 
may be done, either for the purpose of alleviating suffering or with a view of 
restoring the patient to health. What is most to be desired in the early 
months of gestation is the death of the foetus, and for the purpose of pro- 
ducing this two plans have been proposed, one of which is to diminish the 
supply of blood for the development of the embryo by frequent bleedings, 
the quantity of fluid taken being proportioned to the physical condition of the 
patient; and the other, to pass an electric current through the sac in which 
the embryo is contained. These expedients appear to me to be of very doubt- 
ful utility, particularly the first, for how often do we meet with pregnant wo- 
men who by attacks of acute disease have been reduced very much in flesh 
and strength, but in whom there is no apparent effect produced upon the foetus 
other than to cause it to be below the standard in size and weight. In chro- 
nic diseases, where the constitution is defective, it is quite common to meet 



1858.] Harris, Case of Fallopian Pregnancy. 131 



with miscarriages, and births of still-born emaciated infants; but this is due as 
much to the state of the general system as to the want of circulating blood for 
the nutrition of the foetus. Diminishing the amount of the circulating fluid 
by venesection may possibly defer the time of the sac's rupture by preventing 
too great a determination of blood to the point where the embryo is being 
developed; but that it will produce the death of the foetus remains to be 
proved by the future experiments of accoucheurs. With regard to the effects 
to be derived from the use of electricity and galvanism, time will also tell 
whether or no they are to prove of any practical use in the treatment of this 
disease. The value of the electric fluid as a curative agent is as yet very 
imperfectly understood, and every year, almost, introduces some new applica- 
tion of it. As it has been found of use in the treatment of aneurism it is 
not improbable that it may also prove useful in extra-uterine pregnancy, pro- 
vided we can devise some way of applying it to the fecundated cyst so as to 
send the current through its contents without the risk of producing peritonitis. 

The spasmodic pains accompanying preternatural pregnancy are to be treat- 
ed with opiates, and if any signs of inflammatory action are present, with 
antiphlogistic remedies. If suppuration of the sac takes place (an event less 
apt to occur in Fallopian than abdominal pregnancy), and there is any evi- 
dence of a disposition in the abscess to open upon the surface of the abdomen, 
emollient and anodyne poultices should be applied; and an incision made with 
a bistoury, when the abdominal parietes have become sufficiently attenuated, 
for the purpose of giving exit to the pus and the debris of the foetus. If the 
foetus can be felt through the walls of the vagina, the vaginal section should 
be resorted to, or if an abscess point there, the orifice should be enlarged and 
the contents of the sac removed by manual assistance. The rectum may also 
be made the means of communicating with the sac, and a number of cases 
are on record where the foetus, either entire or piece by piece, has been eva- 
cuated through this passage. 

With regard to the operation of gastrotomy in extra-uterine pregnancies, 
there is little to be said that is favourable, and much that is the contrary. 
From the experience of the past, it is to be looked upon as almost as doubt- 
ful an expedient as the ligation of the aorta, yet it has had, and still has many 
advocates among French surgeons. Those who advise its performance, do not 
recommend it in the early months of gestation, unless the patient is in imme- 
diate danger from the prospect of a rupture of the cyst ; and most of its advo- 
cates recommend that it should not be resorted to earlier than the seventh 
month, in the hope of saving the foetus if the parent perishes. Moreau and 
Cazeau, in their late works, strongly oppose the operation while there can be 
any hope of a spontaneous cure, and recommend a resort to it only in cases 
where the pains of parturition have already commenced, and have not yielded 
to efforts made to subdue them. They evidently regard this operation as a 
last faint hope, only to be justified by the speedy prospect of death, and only 
to be performed when every other means is evidently useless. 



132 



Sims, A New Uterine Elevator. 



[Jan. 



Art. XL — A New Uterine Elevator. By J. Marion Sims, M. D., Surgeon 
to the Woman's Hospital, New York. 

Op all malpositions of the uterus, retroversion is the most common. Dr. 
Meigs, who is certainly the highest authority amongst us in obstetric medicine, 
says it comprises 75 per cent, of all cases that fall under his observation. 
Whatever, then, facilitates its removal is of importance to the profession. 
As a means of diagnosis Simpson's sound is perfect, and in many cases indis- 
pensable; but as a remedial agent it is susceptible of improvement. When 
passed downwards and backwards into a retroverted uterus, and then rotated 
half round on its own axis, thus suddenly elevating the organ, it often lace- 
rates the lining membrane, as shown by severe pain and hemorrhage. Besides, 
if the surgeon has unfortunately given it too large a curve, the whole weight 
of the uterus will be sustained upon the point of the instrument as it strikes 
against the fundus, which, we are told, has produced perforation, with fatal 
consequences. This accident, however, cannot happen if the curvature be 
made short, and not more than 2| inches from the end of the instrument; 
for then the weight of the uterus will be sustained principally at the point of 
contact between the anterior lip and the sound at its curvature. But while 
the short curvature obviates the danger of perforation, it does nothing for the 
prevention of pain, and of violence to the uterine cavity. 

I have long thought that Simpson's sound could be improved by making a 
joint or hinge in it near enough the end to prevent its striking against the 
fundus, and yet far enough to allow its fully entering the cavity, which, 
making the os tincse the centre of motion, would enable us to roll the body 
in a right line directly upwards, instead of throwing it round by a lateral 
sweep, as when the instrument is rotated on its own axis. This idea is prac- 
tically illustrated in the Uterine Elevator (see Fig. 2), which the artist has so 
well represented that further description is almost useless. It is about 13 
inches long, and consists of a handle (3 inches), a shaft (7 inches), and a 
uterine stem (2i inches), inserted into a ball which revolves at the end of 
the shaft, its axis being at right angles with that of the instrument. The 
ball is of ivory, about fths of an inch in diameter, and has a belt of perfora- 
tions ygths of an inch apart, extending around in a line with the stem. The 
shaft is a hollow cylinder containing a rod which is retracted at will by the 
slide g, Fig. 2, or pushed forwards by a spiral spring so that its point may 
lodge in any one of the perforations in the ball, whereby the stem may be 
held firmly at any desirable angle with the shaft. 

Fig. 1 represents the upper part of the shaft with its rod a, the ball with 
its perforations, and the uterine stem, all nearly of the exact size and propor- 
tions. Fig. 2 represents the practical application of the instrument. 

The sense of touch is sufficient to show the position of the uterus, and by 



134 Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. [Jan. 

Simpson's sound we measure to the fraction of an inch its depth and degree 
of flexure. Then, and not till then, are we ready for the Uterine Elevator, 
taking care to adjust the stem best adapted to the case. The stem is set at 
the required angle with the shaft, and thus passed into the retro verted uterus 
b, with the ball close up to the os tincse; then, by pulling back the slide g, 
the rod a is drawn out of the perforation in the ball, when it is free to revolve 
in the direction opposite to that of the motor power. Thus by depressing 
the handle and pushing the ball up towards the promontory of the sacrum, 
the uterus becomes further retroverted, but by pushing it gently and firmly 
downwards and backwards into the vaginal cul de sac d, the inevitable result 
is to revolve the stem with the uterus b, directly upwards, as shown by the 
dotted lines ee. The uterus may be arrested at any point of this evolution, 
merely by letting go the slide that holds the rod; or, the movement may be 
continued till it is completely anteverted, while the weight of the organ will 
be sustained mainly by the cervix resting on the ball. There are three stems 
which screw into the ball, one 2 inches, one 2|, and the other 3 inches long, 
but the medium size is the one ordinarily used. Whenever the long or the 
short one may be needed, the previous use of Simpson's sound will indicate it. 
The instrument may be made of silver, of copper silvered, or of German sil- 
ver. I prefer the first two, because the stem often requires a little flexure to 
adapt it to acute uterine curvatures, particularly where there is much carti- 
laginous degeneration of tissue. German silver is not soft enough for this 
purpose. 1 

After the malposition is rectified, it will, of course, require some mechanical 
contrivance to keep it so : whether Meigs' ring, or Hodge's instrument, or 
some of its various modifications, or Simpson's intra-uterine stem, will depend 
upon the peculiarities of the case, and the tact and judgment of the operator. 



Art. XII. — Exsectwn of the Trunk of the Second Branch of the Fifth Pair of 
Nerves, beyond the Ganglion of Meckel, for Severe Neuralgia of the Face: 
with Three Oases. By J. M. Carnochan, Professor of Surgery in the 
New York Medical College, Surgeon-in-chief to the State Hospital (New 
York), &c. 

The accounts heretofore given by authors of neuralgia, or tic douloureux 
of the face, are of a very vague and indefinite character. Numerous essays 
and monographs have been written on this subject, since the time of Fother- 
gill, who published, in 1776, an elaborate description of the disease, which 
attracted considerable attention. In all these efforts, the pathology of tic 

1 The instrument is made by Otto & Koehler, Chatham Street, New York. 



1858.] Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. 135 



douloureux is described with ambiguity. In practice the treatment has been 
as empirical as it has proved to be unsuccessful. The seat of the disease has 
been referred to distant irritations, especially in the splanchnic cavities — to a 
foreign body acting upon the nerve — to the pressure of bone upon some por- 
tion of the nervous trunks. By some authorities, it is referred to increased 
vascularity and thickening of the nerves ; while Astley Cooper, on the con- 
trary, states, that the nerves present their natural colour, and are rather di- 
minished in size than enlarged. It can scarcely be supposed that beneficial 
results should follow from treatment based upon theories so different in cha- 
racter. 

Tic douloureux of the face, proper, or of the second branch of the fifth pair 
of nerves, is by far the most common form of facial neuralgia. This may be 
explained by the more numerous branches, which are given off by this trunk, 
and by the position which these branches occupy — in some places pent up in 
osseous canals, and in others, subjected to exposure, to changes in tempera- 
ture, as well as to the agency of morbific influences, from which the other two 
trunks of the fifth pair are exempt. 

The same laws which govern neuralgic disease of one of the branches of the 
fifth pair, must be applicable to the disease in the other trunks. I believe 
that the phenomena of neuralgia can be explained with as much precision as 
in any other disease, when well understood. In cases similar to those de- 
scribed below, whatever may have been the original exciting cause, I have 
no doubt that the real seat of the disease is in the trunk of the nerve, in 
front of the foramen rotundum — in some part of it, or in the whole of it. 
The causes of the disturbed and changed condition of the trunks of the 
nerve may be numerous — prolonged irritation upon the periphery — expo- 
sure — injuries — tumours; diseases of the teeth — pressure resulting from 
periosteal or osteal thickening of the osseous foramina or canals — sudden 
suppression of any of the important secretions, as of the catamenial dis- 
charge. From one or more of these causes, the trunk itself may be pri- 
marily affected, or acting upon its ramifications, the irritation may be propa- 
gated to it. Prolonged irritation induces inflammation, and this generally 
remains passive or chronic. Some of the terminations of inflammation — such 
as the effusion of lymph among the interstices of the neurilemma or the 
nervous tissue itself — may become developed; leading to a vascular, engorged, 
thickened and enlarged condition of the nerve, or to a softening of it, at one 
or more points. In fact, vascular engorgement, or inflammation, with some 
of its consequences, of the neurilemma alone, or of it and the nerve together, 
by whatever cause produced, is the condition which constitutes the pathologi- 
cal changes in the trunk. 

The three cases related below afford proof of what has just been stated. In 
each instance, the exsected nerve was found to be red, vascular, engorged and 
considerably enlarged. 

The diffused character of the pain can be easily understood, if we take into 
consideration the numerous ramifications of the second branch of the fifth 



136 Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. [Jan. 

pair, and the extensive surface over which their ultimate filaments are distri- 
buted. The periphery of the nerve occupies not only the superficial parts of 
the face, but extends deep amongst the bones of the upper jaw, to the nasal 
fossae, to the septum nasi, to the hard and soft palate, to the pharynx, to 
the inner ear, to the orbit, and to the temporal and malar regions. 

It is well established, that if the trunk of a nerve be irritated along its 
course, the painful sensation will be referred to its periphery. If the ulnar 
nerve, for example, be struck where it passes behind the internal condyle, a 
sensation of pain is excited, which is referred to the little finger and to the 
ulnar border of the ring finger ; and if a prolonged irritation be kept up at 
this point, the skin of these fingers becomes tender to the touch, the sensi- 
bility being very much increased. 

It is by this principle — which governs the action of the stimuli upon the 
nerves of sensation — -in connection with the anatomical distribution of the 
nervous ramifications, that the various phenomena of neuralgia can be ex- 
plained. The disease being seated in the trunk of the nerve, we can readily 
understand that the pain must be referred to the peripheric extremities of the 
nerves, and will there be felt, as long as the branches are in communication 
with the encephalon. 

From these views, we can perceive how futile the operation of division of 
the nerve at the foramen infra-orbitale must be. Where the trunk of the 
nerve is extensively diseased, no operation can rationally lead to a successful 
result, unless all the branches emanating from the trunk are cut off from com- 
munication with the brain , 

I believe that, in such aggravated cases of neuralgia, the key of the opera- 
tion is the removal of the ganglion of Meckel, or its insulation from the en- 
cephalon. — Where even a large portion of the trunk of the second branch of 
the fifth pair has been simply exsected from the infra-orbital canal, the gan- 
glion of Meckel continues to provide to a great extent the nervous ramifica- 
tions, which will still maintain and keep up the diversified neuralgic pains. 
Besides, the ganglion of Meckel, being composed of gray matter, must play 
an important part as a generator of nervous power, of which, like a galvanic 
battery, it affords a continual supply ; while the branches of the ganglion, un- 
der the influence of the diseased trunk, serve as conductors of the accumu- 
lated morbid nervous sensibility. 

Case I. — Henry Rousset, a French physician, residing in Greensborough, 
Caroline County, Maryland, consulted me in the early part of October, 1856, 
for severe neuralgia, which had for several years rendered him incapable of 
following his profession. He was of nervous temperament, good constitution, 
and sixty-nine years of age. 

The disease first made its appearance in September, 1851, commencing 
with severe and lancinating pains about the region of the left cheek and orbit. 
These pains continued for five or six days, and then disappeared, leaving him 
almost free from them for about four months. At the expiration of that 
time, the neuralgic pains again returned with more violence, extending over 



1858.] Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. 137 

the region of the left cheek, and continuing almost without intermission, for 
more than a week. After this exacerbation, the patient again became com- 
paratively free from pain for a short interval ; after which, the attacks re- 
turned with increased severity, and were renewed with greater frequency, 
more especially in the cold season, and in damp weather. As the disease 
progressed, the pain was not confined alone to the eye and cheek, but would 
also attack the lip and nose ; each paroxysm being of longer duration than 
the preceding. With but slight variation, the disease went on in this way 
to harass and distress the patient for four years. About the commencement 
of March, 1856, the neuralgic exacerbation assumed a more violent form, 
marked by excruciating and almost unremitting suffering. He was at this 
time unable to eat, drink, converse, or laugh, without having a most violent 
paroxysm, causing him to shriek in anguish. The paroxysms were more se- 
vere during the night than day : sleep left him : his constitution began to 
give way, and his mind became much enfeebled. The slightest touch upon 
the surface of the face, a current of air or a mouthful of water acting on the 
palate, would throw the patient into a violent paroxysm of agony. During 
this long period of suffering, all the known remedies which have at times been 
extolled for neuralgia of the face had been tried — narcotics, tonics, antispas- 
modics, with counter-irritants, and galvanism, without producing any appre- 
ciable result. In this distressed condition, the patient, wearied of existence 
and unable any longer to endure a life so made up of excruciating torture, 
presented himself to me for my advice, at the beginning of October, 1856. 
He expressed himself willing to undergo any operation, however severe, which 
held out the prospect of relief. Having no internal remedy to propose which 
had not already been administered, and having no faith in the mere division 
of the nerve upon the face, I proposed to him the exsection of the trunk of 
the second branch of the fifth pair of nerves to a point beyond the ganglion 
of Meckel. Being a physician himself, I explained at length my views (as 
expressed above) in regard to this malady. He immediately consented to 
have the operation performed, and desired that the earliest time should be 
appointed. I consequently agreed to perform the operation the following day, 
the 16th of October. 

Operation. — The principal instruments necessary for this operation are a 
trephine, the crown of which is three-quarters of an inch in diameter, an 
elevator, chisels of different shapes and sizes, a leaden or iron mallet, the bone 
forceps of Luer, small pieces of sponge tied to a stick or a piece of whalebone, 
and a small fixed trephine of half an inch in diameter, which may be used to 
perforate the posterior wall of the antrum. The assistants being properly 
arranged, the patient was seated upon a solid chair, opposite a good light, 
and was put under the influence of chloroform. The head was rested upon 
the breast of an assistant, who maintained it in this position. An incision 
was now made on the cheek, commencing near the internal angle of the eye, 
on the inferior edge of the orbit, opposite the anterior lip of the lachrymal 
groove. This incision was carried downwards and slightly outwards, for 
about an inch, to a point opposite to the furrow on the lower portion of the ala 
of the nose; another incision, which also terminated at this point, was made, 
commencing about half an inch below the external angle of the eye, opposite 
the edge of the orbit, thus forming a V incision, in the area of which is 
situated the foramen infra-orbitale. The flap thus resulting was thrown up- 
wards, and the branches of the second branch of the fifth sought for; some 
of these being found, they served as a ready guide to the trunk of the nerve. 
This was now isolated from the surrounding tissues up to the poiut of exit 



138 Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. [Jan. 

upon the face from the foramen. The lip was now everted, and the mucous 
membrane detached from the superior maxilla along the line of junction be- 
, tween the cheek and the gum. A sharp-pointed bistoury was now inserted 
at the apex of the V incision, into the mouth, and carried downwards, so as 
to divide entirely the tissues of the cheek and upper lip, along a line passing 
midway between the ala of the nose and the commissure of the lips. The 
two flaps thus formed were now dissected from the osseous tissue beneath, 
one being reflected outwards, towards the ear, the other internally, towards 
the nose. The whole front wall of the antrum maxillare, with the nerve 
passing through the foramen infra-orhitale, was thus exposed. The crown of 
the trephine was now applied on the anterior wall of the antrum, immediately 
below the foramen infra-orhitale, and an irregular disk of bone removed, so 
as to expose freely the cavity of the antrum. The circumference of the fora- 
men, the hardest portion of the canalis infra-orbitalis, was now destroyed by 
Luer's forceps, and a small chisel. The trunk of the nerve was now traced 
along the osseous canal in the floor of the orbit, which was broken down with 
care, so as not to encroach upon the tissues in the cavity of the orbit. Ar- 
riving at the back of the antrum, the posterior wall of this cavity was broken 
down with a small chisel, and the portions of bone removed. The trunk of 
the nerve was now still further isolated from the other tissues in the spheno- 
maxillary fossa. The posterior dental nerves being divided, and the dis- 
section being carried still further, the branches given off to form the ganglion 
of Meckel, were reached. These were divided, and also the branch given off 
to run up towards the orbit. Lastly, by the use of blunt-pointed scissors, 
curved on the flat side, the trunk of the nerve was divided from below up- 
wards, close up to the foramen rotundum. The hemorrhage was not very 
profuse, the labial arteries being easily controlled by pressure of the fingers, 
and the branches of the internal maxillary artery, in the spheno-maxillary 
fossa, by dry lint, or what is better, the compressed sponge. The lips of the 
wound were brought together and maintained in place by thirteen points of 
twisted suture, the German or Carlsbad pins being used. 

This severe and trying operation is perfectly justified by the fearful nature 
of the disease for which it was projected. It is one of those operations which 
could not be supported by the patient without the influence of chloroform. 
The handling of so large a nervous trunk with the forceps, and the necessary 
contact with the hard instruments, while separating it from its surrounding 
connections, would, I suppose, be beyond human endurance, without the aid 
of the anaesthetic influence of chloroform or ether. For the rest, the effects 
of the cicatrices upon the countenance can scarcely be called disfiguring, and 
the patient speedily recovers without suffering from much constitutional dis- 
turbance. 

In this operation, and in those connected with the two succeeding cases, I 
was assisted by my colleague Prof. Cox, by Drs. Proudfoot, Abrahams, Sel- 
den, Gi-uleke, and Casseday; and by my pupils, Messrs. Dougherty, Henry, 
Scudder, and others. 

Condition of the Nerve. — The trunk of the nerve in this case was much 
larger than natural in nearly its whole extent. The neurilemma was very vas- 
cular, and the nervous tissue proper was also engorged and red ; the trunk, 
after its removal, was so red as to have somewhat the appearance of muscular 
tissue. The length of the nerve removed was a little more than an inch and 
three-quarters. The lining membrane of the antrum was sound, as well also 
as the bones of the antrum and the osseous wall of the canalis infra-orbitalis. 

Progress of Union and After-treatment. — Oct. 16/A. Six hours after the 
operation, the patient was visited. His pulse was 100; there was a slight 



1858.] Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. 139 



fever; lie complained of thirst, and lemonade was ordered. He spoke of a 
desire he had to vomit, which he ascribed to the chloroform. He stated that 
he felt slight twitchings on the nose, and at the corner of the lip. 

11th (Friday). The patient was remarkably well under the circumstances; 
sitting up; pulse 90; tongue lightly covered with a white fur; complained 
of pain in the wound, also of shooting pains in the left eye; he remarked 
that he could stick a pin into the upper lip and cheek without causing pain, 
there being no sensation in that region. Ordered chicken broth, and wine 
and water. 

18th (Saturday). Patient improving; wound healing; pulse natural; no 
fever; spoke of the numbed sensation in his faee. 

19th (Sunday). Pulse full and natural; good appetite; partook of a beef- 
steak; in the afternoon four suture pins were removed; slight pain in the 
wound ; no return whatever of the neuralgia. 

20th (Monday). Cure progressing ; healthy suppuration from wound; ap- 
petite excellent ; general health much improved. 

(Tuesday, Wednesday, Thursday). During these days the rest of the pins 
were removed; patient felt no pain whatever either in the wound or cheek; 
wound in the antrum syringed with tepid water. 

25^ (Sunday). Patient attended church ; feels no pain whatever; incision 
of the upper lip and cheek entirely healed. 

2Sth. Patient entirely well. 

30^. Returned home to Maryland in high spirits, and delighted at the 
result of the operation. 

December 7th y 1857. Fourteen months after the operation he writes to me 
that he is enjoying excellent health, and has been entirely free from neuralgic 
pain. 

Case II. — Florence Cordello, a native of Italy, aged 54 years, of lymph- 
atic temperament, chocolate maker by trade, was admitted to the State Hos- 
pital on the 14th of September, 1857, suffering from severe tic-douloureux of 
the left side of the face. The following is the account handed to me by the 
Assistant Surgeon, Dr. G-uleke. In the year 1828, the patient contracted a 
very severe cold from exposure, and about this time he was seized with the 
pain for the first time. According to his own description, the pain started 
from the foramen infra-orbitale, extending upwards to the forehead, and 
downwards into the teeth; the paroxysm lasting about ten minutes. He 
supposed it to be toothache, and had one or two teeth extracted. An inter- 
val of eight years took place, when he was again attacked with neuralgic 
paroxysms, lasting from five to ten minutes. Again, after the lapse of a 
year, the paroxysms reappeared in a more severe form, and at shorter 
intervals. 

The patient, still believing his teeth to be the source of the disease, had 
all of them extracted on the left side of the upper jaw, but without any be- 
nefit. During these attacks he had been subjected to many kinds of treat- 
ment, both internally and externally : he also repaired to some of the mineral 
springs on the Rhine, but still to no purpose. He continued thus to suffer 
more or less intensely from the neuralgic paroxysms, for a period of time 
extending from 1837 to 1846, and with detriment to his general health. 
In 1846, while passing through the city of Heidelberg, in Germany, he con- 
sulted the celebrated Chelius with the hope of obtaining some beneficial 
result from his advice. That professor divided the nerve as it emanated from 
the infra-orbital foramen, by incisions from the mouth, and six weeks after, 



140 Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. [J an. 

again performed the same operation, without any favourable result. During 
the next six years the patient continued to suffer from the neuralgic parox- 
ysms of more or less intensity. 

Oppressed by extreme suffering, he again sought relief from an operation, 
and in 1852 the nerve was again divided from the mouth by forcing up the 
lip ; the actual cautery being at the same time applied, by pushing the in- 
strument from the mouth upwards into the wound as far as the foramen infra- 
orbitale. This operation appeared to give some relief, and during the two 
succeeding years, the patient's sufferings were somewhat alleviated. About 
two years ago, the paroxysms returned in the most aggravated form, pro- 
gressed, and continued without much abatement. He, on the 1st of Sep- 
tember last, being in New York, again submitted to an operation for division 
of the nerve. This time, the branches of the nerve were divided by cutting 
through the integuments directly upon the infra-orbital foramen j this opera- 
tion caused no other effect than insensibility to the touch in the soft tissues 
near the infra-orbital foramen. Two weeks after this, he entered the State 
Hospital. The condition of the patient was then as follows: Notwithstand- 
ing the repeated division of the nerve, there was sensibility to the touch over 
the whole region of the cheek ; the inner side of the lip alone appearing to 
be insensible. The patient describes the pain as starting from the foramen 
infra-orbitale and extending up as far as the lig amentum palpebrse internum, 
and also to the external corner of the eye ; from the latter point, the pains 
shot down in nearly a straight line to a point about one inch to the outside of 
the left corner of the mouth, and a little below a line drawn horizontally on 
a level with the commissure of the lips. The pains also extended backwards, 
through the more deeply seated portions of the face, shooting from the inner 
corner of the eye, along the base of the nose, and striking backwards towards 
the spheno-maxillary fossa. The pain was of the true neuralgic character, 
and so intense as to drive the patient into a condition verging .on delirium. 
A slight touch on the cheek, the inside of the mouth, or on the hard or soft 
palate, swallowing, or speaking, excited almost instantaneously the paroxysms 
in their severest form. 

The Operation. — The operation in this case was performed after the same 
manner as the preceding, and was modified only by the greater depth of the 
antrum and face. There was also more hemorrhage from the spheno-maxillary 
fossa; this was controlled by compressed sponge pressed into the fossa. Sup- 
posing that hemorrhage might return, the lips of the wound were brought 
together by adhesive plaster, one suture only being used. The other'sutures 
were inserted the following day. The nerve was cut from above downwards. 
The ganglion of Meckel was drawn out, hanging to the trunk of the nerve. 

Progress of Union and After-treatment. — Compressed sponge was applied 
in the deeper portion of the wound ; the external surface was closed with 
one suture ; an anodyne was ordered for the night. 

Oct. 11 (Sunday). Patient slept well during the night; pulse 76; no 
bleeding; five suture-pins applied; ordered an anodyne. 

12th. Patient slept well; no pain whatever; pulse 84; complained of 
thirst; but little appetite ; speaks and swallows without pain. 

ISth. Slept badly; had an attack of dysentery; pulse 96; felt a slight 
pulsating pain in the wound, which, however, was doing well; states that 
there is no feeling over the surface of the left cheek from the inner angle of 
the eye, descending along the nose to the lip, and upwards to the* outer angle 
of the eye, including the lower lid; ordered opium and quinine. {Afternoon), 
dysentery subdued; pulse 96; more cheerful. 



1858.] Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. 141 

14th. Patient improving; pulse 92; a portion of the pins removed. 

15th. Kemaining pins removed; wound presents a healthy appearance ; 
pulse natural; slight. pain felt in the course of the wound. 

16th. Kemoved the piece of compressed sponge, which had been placed at 
the back of the antrum during the operation, to restrain the bleeding from 
the spheno-maxillary fossa. 

18th. Patient doing well; eats well, and sleeps naturally. 

2Qth. Still entirely free from neuralgic pain ; the whole expression of the 
face changed from that of suffering and anxiety, to cheerfulness and serenity. 

2Sth. Discharged from the hospital entirely cured, and in good health and 
spirits. 

Dec. 8. Visited the hospital; still free from pain and in good condition. 

Condition of the Nerve. — The nerve in this case, as in the previous one, 
exhibited a similar appearance. It was thickened, vascular, and engorged. 
The neurilemma and proper tissue of the nerve were both affected. The length 
of the trunk removed was two inches. 

Case III. — Mrs. Mary Gr. Stevenson, a native of Portsmouth, England, 
and who had borne children, 55 years of age, of full habit and sanguineous 
temperament, consulted me in the month of September, 1857, for severe 
neuralgia of the left side of the face. She had been a resident of the North- 
ern States for thirty years, and had enjoyed, generally, remarkably good 
health. 

On the 12th of August, 1851, while eating a plum in her garden, she was 
suddenly seized with a vivid shock of pain, commencing on her cheek, and 
passing through her jaw, as if caused by a sharp-pointed instrument, suddenly 
driven through her face ; shooting pains of this character, with intermissions 
of entire abatement, Continued for several days. A dentist was consulted, 
who, attributing the symptoms to the teeth, extracted several of them, but 
without the slightest benefit to the patient. The paroxysms continued with 
more or less severity for two months. 

At the end of this time, they suddenly abated in their severity, and the 
respite lasted for about six weeks. Upon hearing of the sudden death of a 
friend to whom she was much attached, the paroxysms were again renewed ; 
they became more frequent; the intervals were shorter, and the intensity of 
pain was increased more and more with each succeeding attack. During the 
year 1852, the pain and paroxysms still continued with unyielding severity. 
The tic would now last for two and three months, with scarcely any of the in- 
tervals which had heretofore occurred. Cold air, the drinking of fluids, the 
slightest touch upon the cheek, or any sudden mental emotion, would inva- 
riably excite the most fearful paroxysms. During the year 1854, her condi- 
tion was not in any way ameliorated; the pain, if possible, was more severe, 
and her general health suffered from the want of rest. During the year 
1855, the disease progressed with the same severity. In the early part of 
the year 1856, the paroxysms became still more aggravated; the patient, at 
times, becoming almost delirious — starting up, running about her room, and 
screaming like a maniac. In the latter part of September, she sought relief 
from a surgeon in this city, who divided by subcutaneous incision the branches 
of the infra-orbital nerve, as it issues from the infra- orbital foramen. 

About this time, she also took large quantities of various narcotics, and of 
the carbonate of iron. After the operation, she experienced some relief. 
The amelioration continued from October, 1856, until May, 1857, when the 
paroxysms were again renewed in their severest form. 
No. LXIX.— Jan. 1858. 10 



142 Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. [Jan. 

The pain now became almost continual, depriving her nearly entirely of 
sleep ; she was unable to eat without torture, the act of swallowing invariably 
bringing on a paroxysm. During these exacerbations, the pain was diffused 
in different directions, extending from a point a little below the infra-orbital 
foramen, or from the ridge of the gums, and striking through the superior 
maxillary bone towards the deeper portions of the face, and towards the orbit, 
and sometimes extending towards the region in front of the ear. She de- 
scribed the pain as of a beating character at times; each shock succeeding 
another in rapid succession, as if keeping time with the ticking of a clock. 
During this long period of suffering, she had been under the alternate care of 
several physicians; the various remedies most approved of in this kind of disease 
had all been faithfully and sedulously tried; stramonium, aconite, belladonna, 
hemlock, opium, morphia, chloroform, carbonate of iron, valerianate of ammonia, 
and other medicaments had been administered internally; while externally, 
in addition to the division of the nerve, blisters, sinapisms, hydrocyanic acid 
liniment, tincture of aconite, and chloroform had been resorted to — also elec- 
tricity and galvanism. At the time I was consulted, she was suffering night 
and day from repeated and excruciating attacks, and, as she herself stated, 
she had visited the city to have an operation performed at all hazards, how- 
ever desperate it might be, if I could only hold out any prospect whatever of 
its affording relief. Her general health was tolerably good, and she did not 
complain of loss of appetite. I explained to her the nature of the operation 
which I believed to be the only one suited to her case. She immediately 
assented to submit to it as early as possible. 

The operation was performed after the same procedure. The face was in 
this instance, also, very deep. The hemorrhage from the spheno-maxillary 
fossa was considerable, and was stopped by a piece of compressed sponge to 
which a strong ligature was attached, by which it could be removed. 

Progress of Union and After-treatment — Nov. 5 (Thursday evening). As 
soon as the operation was completed, the patient retired to her bed. Vomit- 
ing came on a few hours after, owing, probably, to the quantity of chloroform 
which had been used. 

6th. Had slept tolerably well during the night; felt very little pain; pulse 
80; no fever; complained of some pain in the wound, but had no neuralgic 
pain. 

7th. Left side of the face slightly swollen; puffiness about the eyelids; 
has no pain; has slept well without any anodyne; states that she feels better 
than she has for months; pulse 80; skin natural; slight thirst; five of the 
suture pins removed; line of incision looks as though union by first intention 
was going on favourably. Still kept on fluids for nourishment — gruel, rice- 
water, ice-water, toast-water, and chicken tea. Ordered a gentle aperient. 

8th. Had slept well; tumefaction of face subsiding; complains of head- 
ache; cloth wetted with cold water applied on forehead; same diet continued : 
pulse natural ; removed the sponge which was used to stop the bleeding 
from the spheno-maxillary fossa ; this came away without any difficulty by 
slight traction, a little blood following. Complains of slight pain in the orbit. 
Removed six suture pins, leaving one only — that uniting the free border of 
the lip. Fluid diet as before. 

9th. Patient slept well ; headache less; pulse 78; no neuralgic pain; a 
weak solution of the tincture of arnica ordered, to bathe the cheek with ; 
removed the last pin ; union by first intention, along the line of incision, 
complete. 

From the 9th until the 16th all has progressed favourably. No neuralgic 



1858.] 



King, Catalepsy treated with Nitrate of Silver. 



143 



pain whatever; sleeps well; swelling on cheek diminishing; pain has entirely 
left the orbit ; secretion into the mouth from the wound in the antrum dimi- 
nished. Ordered a gargle of the tincture of myrrh. Appetite has also re- 
turned. Had been sitting up, and walking about her room without any 
inconvenience. Has taken a little sulphate of magnesia ; has not required 
any anodyne. 

Dec. 3. The patient has been progressing favourably up to this time. The 
wound has healed entirely, the line of cicatrix is becoming effaced; not the 
slightest trace of tic douloureux remaining. There is no paralysis of the 
muscles of the face upon the side operated on. 

In the case of this patient, the nerve was enlarged, very vascular, thick- 
ened and red. Two inches of the nerve were removed. 

45 Lafayette Place, New Yokk, Dec, 1857. 



Akt. XIII. — A Singular Case of Catalepsy successfully treated with the 
Nitrate of Silver. By Wm. K. King, M. D., of Louisburg, N. G. 

The patient was a girl aged 11, delicately formed, dark complexion, black 
hair, with unusually brilliant black eyes, sprightly countenance, quick spoken, 
and playful in manners. She had a slight attack of sickness during the 
month of August, 1856, accompanied with fever and headache. However, 
her symptoms were so mild that her parents considered it unnecessary to call 
in a physician. She soon recovered, but during convalescence it was ob- 
served that she occasionally became affected with spams, chiefly in her upper 
extremities. 

I was called to visit her in consultation with the family physician, and very 
soon after approaching her bedside she had spasms in the upper and lower ex- 
tremities, which I supposed was caused by mental agitation at the sight of a 
stranger. The fingers and toes were in a semiflexed position, the feet being 
extended in a line with the legs, which were in a rigid state of spasm, also the 
arms throughout their length. The spasm was of the tonic order, the parts 
remaining perfectly rigid, which required considerable force to overcome. The 
limbs remained in every position in which they were placed, as in ordinary 
cases of catalepsy. She was conscious of all things around her, and answered 
questions promptly, though in a subdued tone. Her pulse was accelerated and 
small, but became greatly reduced in frequency when she was free from spasm. 
Her father remarked that she would remain in that condition an indefinite time, 
unless the contraction of the muscles was overcome by force; whereupon he ex- 
tended the fingers, which caused an immediate relaxation of the spasm of the 
upper extremities, but the legs and toes remained fixed until the same pro- 
cess of " unlocking" (to use his own language) was performed, when she im- 
mediately assumed a happy and playful countenance as formerly. Pressure 
on the nape of the neck, where I found considerable tenderness, also on the 
crown of the head, over a space about the size of the palm, would immediately 
produce the same state of things. Sweeping the floor, patting the foot, saw- 
ing wood, and all harsh or grating sounds, from whatever cause proceeding, 
had the same effect. If she was in a profound sleep the floor could not be 
swept ever so softly without awaking her and causing spasm to some extent. 



141 King, Catalepsy treated with Nitrate of ' Silver. [Jan. 

The treatment consisted, first, in a mild purgative course with blue mass, 
&c, followed by the valerianate of zinc, with counter-irritation over the 
cervical vertebrae and subsequently the various chalybeate preparations were 
tried, but without any improvement whatever in her condition. This plan 
of treatment was pursued for several months at irregular intervals. 

My second visit was made some time during the month of May last, when 
I found the same symptoms existing, and in some respects in an aggravated 
form, although on my arrival I found her at play. Pressure on the crown of 
the head, as formerly, produced spasm commensurate with the amount of 
force applied. At one time it became so violent as to cause considerable 
distortion of the features by a spasmodic action of the muscles on the right 
side of the face, as well as the right oblique muscles of the eyes, drawing the 
globe considerably to the right and downwards. She became speechless, 
but retained her consciousness. Whenever she was thus violently affected, 
which her father informed me was not often, he could not unlock her in the 
usual mode of extending the semiflexed fingers and toes, but would take her 
in his arms and toss or swing her to and fro, when a sudden relaxation fol- 
lowed. 

The tenderness which was found to exist over the cervical vertebrae at my 
first visit had now been transferred to the four lower dorsal and lumbar 
vertebrae, over which there was considerable tenderness. Appetite and diges- 
tion good. 

The treatment was renewed with J gr. doses of the nitrate of silver three 
times a day, gradually increased to J gr., with counter-irritation with strong 
croton oil liniment over the tender vertebrae, under which she rapidly im- 
proved and entirely recovered from all nervous disorders. Whenever, during 
the treatment, she complained of headache or any other cerebral disturbance, 
the nitrate was suspended for a while, and the bowels gently moved with 
small doses of blue mass, followed by a saline cathartic or castor oil. The 
patient will be kept upon some mild chalybeate until her general health 
is thoroughly invigorated ; but she has been for many weeks entirely free 
from all her former symptoms. There remains considerable tenderness of the 
scalp and vertebrae, and pressure applied to either part causes much pain, but 
without the slightest spasm of any of the muscles. Her general appearance 
is now good, complexion beginning to assume a healthy hue j and her gait, 
which formerly was cautious and somewhat tottering, is now nimble and 
strong. 



1858.] 



145 



REVIEWS. 

Art. XIY. — Elements of Pathological Anatomy. By Samuel D. Gross, 
M. D., Professor of Surgery in Jefferson Medical College, &c. Third edi- 
tion, modified and thoroughly revised. Illustrated by 342 engravings on 
wood. Blanchard & Lea: Philad, 1857. 8vo. pp. 771. 

This book may be considered as a representative work. It marks the level 
of the anatomical school, being just such a book on pathological anatomy as 
an intelligent surgeon of large experience might be expected to write. This 
understood, nobody, who begins with the title page and reads perseveringly, 
need be disappointed. The reader, who confidingly accepts the guidance of 
Dr. Gross, will be conscientiously led over the whole surface of the domain 
justly belonging to pathology, and will find the way very pleasantly beguiled 
by clear and simple descriptions. Measurements will be given with scrupu- 
lous exactitude — and the hues of all objects that have colour will be noted 
down to the most delicate shade. He will learn the feel and the smell of every- 
thing wnich can come within reach of his digits and nose. He may gain a 
complete acquaintance with the whole outside of pathological anatomy by 
means of Dr. dross's introduction; but, after all, it is as incomplete and un- 
satisfactory as to attempt to know a man by looking through the windows of 
his dwelling. 

How anatomy may be studied, and how anatomy should be taught, are 
general questions of no little practical weight, and we propose- — since we have 
so little reason to find fault with the facts contained in the book before us, 
which are really inexhaustible in amount and stated with admirable clearness 
and simplicity in most cases — to draw the reader's attention to the errors 
of philosophic method which belong to this, in common with a large class 
of treatises on pathological anatomy. It is of no avail to sneer at medi- 
cal philosophy, or to assert that there is nothing to represent it but preten- 
tious folly. Every medical man has a medical philosophy which is rooted in 
the groundwork of his nature — close by his politics and his religion. And 
every medical book represents in some sense, a phase of medical philosophy. 

All the systems of anatomy, and all the individual students of anatomy, 
divide themselves by a natural repulsion, into the two classes which represent 
with more or less exactitude, the modes by which almost all the subjects of 
human observation and speculation may be approached. There is an esoteric 
and an exoteric phase for all matters of sight and subjects of faith. Philo- 
sophers, theologians, poets, social reformers, mathematicians, painters, music- 
makers, as well as anatomists, classify themselves on this basis. Thus we 
find Serres, Oken, Owen, Paget, De Blainville, Bobin, and Bouchut standing 
vis-a-vis to Kolliker, Lehmann, Quain, Carswell, and Gross; Locke stands 
versus Schlegel and Comte; Malthus against Coleridge; Tennyson and Keats 
against Scott and Campbell; Edwards against Fenelon; Louis Napoleon 
against Prudhon ; Buskin against Joshua Beynolds ; Bellini against Wagner, 
and Prof. Pierce against Merriam. 



146 



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[Jan. 



Had all these men studied medicine, it were easy to conceive from what 
point of view each one would have looked at life, health, and disease. Look- 
ing closely at these disputants we should see, on the one hand, the Anato- 
mists, pur sang, who work from without inward ; from the particular towards 
the general; from the material form towards the msaisissable ; from special 
organs towards developmental principles — but without attaining so far, as a 
matter of course. Most of them fall short in the pursuit and lose sight of 
the end of biological investigation. " How hard it is to compass the means 
by which one mounts to the fountain head ; and before he has got half way, 
a poor devil must probably die !" said the wearied student who began at the 
wrong end of the tangled thread. Anatomists may travel all over the pal- 
pable and the sensible with great assiduity and keenness of vision, and with 
"best luck catch only a fox." But they go with knowledge and safety as 
far as they go— -taking care to affix one end of their telegraphic wire to a 
rocky fact on shore, before starting off into the deep with the other. This 
class is well represented in our Young America School, and is unquestionably 
oa the right course ; we would only ask of it, to look a little deeper through 
solidism and humoralism till it arrive at the apprehension of the dynamics as 
well as the statics of life. 

Among the Vitalists are men of broader view and deeper ken — men who 
possess capacity for large generalization. But most of them overleap and 
outrun the slow rolling ball made up by toilsome investigation, and playfully 
knock about hypotheses like snow-flakes. For Stahl, Boerhaave, and the 
school of Montpellier, the study of pathological anatomy could have but little 
interest. They do not need pegs to hang their theories on, for most of them 
are lighter than air, and keep quite out of sight. The men of this class are, 
for the most part, unsafe practitioners of medicine, having an unequivocal 
leaning towards mediseval therapeutics; yet they are clinging to a great truth, 
while plodding near-sighted skeptics are scratching the earth's surface in 
quest of the No^oj, and measuring cranial bumps to gauge the divinity that 
has its throne inside. They have apprehended a great underlying fact, but 
they forget that vital force is not an entity, but only a "special property" of 
organic structures. 

Out of the midst of these is developing the new school. Its basis is broad and 
its aim is high. These thinkers have found out that there can no more be an 
absolute solidism, than an absolute vitalism, and there can no more be either of 
these than matter without spirit, or spirit without matter— the power without 
the deed. Thus escaping the "coarse hypotheses of materialism, and the ab- 
surd logic of immaterialists," they are promulgating the doctrines of modern 
Organo- Vitalism." of which De Blainville, Bobin, Bouchut, and Littre are 
the ablest exponents. They talk rather of general than of local disease— of 
idiosyncrasies, inheritance, types, diatheses and morbid elements more than 
of the numerical force of so many cases collected^ or of the colour, size, weight, 
and consistence of hepatized structures. 

These are not differences without consequence — they are of primal import- 
ance. But we should not dwell upon them at this time if we did not, in the 
book under consideration, see practical errors directly traceable to what we 
believe to be faults of philosophy — and, not only in this book, but in all the 
libraries and in all the lecture-rooms the lookers from within face the lookers 
from without. What coincidence of opinion can there be when the first prin- 
ciples fly apart to the two poles. Let us look at it in the common questions of 
the time. To one mind, puerperal fever appears simply as the result of ute- 



1858.] 



Gross, Elements of Pathological Anatomy. 



147 



rine phlebitis, or peritonitis, or inflammation somewhere else about the •womb, 
or its appendages. While to another, puerperal fever is plainly an example 
of blood-poisoning, manifesting itself in the particular locality which it selects 
through the accidental circumstances of the patient's child-bed condition. 
For this observer it is as much a case of blood-poisoning as is scarlatina with 
its local excitements and exudations, or hospital erysipelas. 

Again, pneumonia appears to one to be simply an inflammation of the 
lung — and, since inflammation is a unit — a uniform, well-defined, and inva- 
riable condition appertaining to all organs and tissues — as a matter of course, 
inflammation of the lung does not differ in essence or phenomena from inflam- 
mation of the subcutaneous tissue produced by a foreign body. While on the 
contrary, the same pneumonia is regarded by the deeper searching eye as a 
general disease. It may have arisen from a local irritation — as from the ab- 
sorption of some morbific material— (but if in this way local, the primitive 
effects are not with any certainty to be found in the lungs); but, when fairly 
germinated, it is an essentially general disease, manifesting itself by various 
phenomena, among which are pulmonary softening, with an afflux of blood ; 
exudation of serum and fibrin; new formations of cells and globules, and 
the retention of chlorides which should have been eliminated with other 
urinary elements. The heat of skin and purple flush of cheek are not results 
necessarily of the impairment of respiratory function. Still further to illus- 
trate this point, let us select an erysipelatous cynanche; to one, it appears as 
nothing more than a sore throat, and is treated as such, notwithstanding the 
preceding chill, headache, and pains throughout the limbs. Another, to 
whose mind the succeeding blush over a square inch of mucous surface seems 
an inadequate cause for a preceding malaise, looks upon the quinsy as the 
counterpart of the rose spots of typhoid, the herpes of catarrh, and the semi- 
lunar whorls of measles. 

We think it of the first importance that teachers should impress upon their 
pupils a sound, approximately sound, philosophy. There have been many 
who have affected a disgust for all hypotheses and philosophies of medicine. 
Thus raising the old question of the Dogmatists and the Empirics, who were 
debating in the time of Celsus, and have not yet settled the dispute between 
them, whether there can be a speculative medicine, and whether all the ac- 
cepted facts and ideas of medical science were or were not based upon empiric- 
ism. This oscillating point has not yet been fixed, nor has such a consum- 
mation been possible till the late advances in general natural history, had 
established certain bases, from which a science could be constructed from the 
known towards the unknown. To-day, says an enthusiast, we may boast that 
we have the knowledge of a speculative system of medicine, and it has been 
every day of these last years developing itself before our eyes by means of 
investigations which more and more demonstrate the relations of pathology to 
biology. All the facts and recognized principles of pathological anatomy are 
based upon general anatomy, just as those of pathology rest upon general phy- 
siology. Thus medicine, the medicine of the future, is fast coming to that 
state of promise when its foundations shall be as sure as those of the science 
of life; and the reproach uttered by Cruveilhier acknowledged to be unde- 
served, for it will no longer be true, that il n'y a d' autre calcul possible que le 
calcul des probabilites. The most hopeful would undoubtedly confess, how- 
ever, that many questions presented to the student of medicine must, from 
their very nature, forever remain without positive solution. 

As there are different ways of practising medicine, so are there various 
modes of studying the science, which is the living spirit of the art. When 



143 



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[Jan. 



we give advice, we say : at the beginning let every one seek out and take to 
himself a stock of good definitions. Many a man goes the wrong way on 
account of a bad definition working in his head, and quite as many go with- 
out persistence or certainty, because they have no definitions and never had 
any, and have never found out that they wanted any. A beloved preceptor, 
ever to be remembered with reverence, was accustomed to say, when you 
get a new book, read the Pre/ace and pick out all the plums of definitions, 
for they give the flavour. When you have the definitions look for the 
classification, and then you have hold of your man, and you know at once 
whether you can get on together, and if it will be of any use to seek a more 
familiar acquaintance. But avoid the mistake of Pinel, who, while he believed 
justly in a good classification and thought that a correct nomenclature would 
accomplish the perfecting of medicine, was not careful of his facts, but, as 
Louis asserts, trusted to his young pupils for the collection of them. Whether 
the proposition, la medecine est tout entiere dans V observation, be accepted 
or not, the following one is indisputable : IS incertitude des connaissances 
me die ales tient a la fois a une observation imparfaite des /aits particuliers, 
et a la maniere non moins imparfaite dont ceux-ci sont etudies. — (Louis, 
Mem. de la Soc. Med. d' Observation?) 

We ask, then, at the start, for good definitions. Those who write books 
on pathological anatomy must expect to be catechized on first principles. 
The student comes up and he wants to know, he persists ; and so we inter- 
rogate the teachers. We ask them, before we care to hear about the effects 
of the dead man, what is life, and what is death, and what are health and 
disease? It can be seen at first glance that this departed person has gone 
off and left his cadaver with, perhaps, a tumour on it about the size of a 
cocoa-nut, and of the consistence of white-oak cheese. But that does not 
tell us the half; and is, in truth, a very useless piece of intelligence if we do 
not associate with it an immense amount of other intelligence. The tumour 
is not the disease, nor does it tell much about its antecedents, nor does it 
more than hint at all the consequents of the disease. But this is such a pal- 
pable truism that one need not utter it if it were not also just as true that 
most books on pathological anatomy are deficient in that amount of other intel- 
ligence which everybody sees is essential and needed, but which nobody, in 
the ranks of the pure and simple pathological anatomists, seeks to supply. To 
look at that man's cadaver and his cheesy tumour with persevering penetration 
will not enable us to persuade the next man not to leave his cadaver in the 
same way. We fear there has been a fearful waste of material in this cutting 
up business. Cutting up must be done. There can be no getting at the truth 
in a cytoblast without cutting up. But let it be done with the expectation of 
finding only the coarse and altered illustration of a small part of the complex 
processes which preceded death. Some teachers of pathological anatomy have 
wofully misled their pupils by pictures of disease, which have only the outlines 
of morbid specimens for their frames. There is a science of diseased anatomy 
which is a part of the foundation-structure of medicine, but its investigations 
are commenced upon the living body. Many acknowledge this in the abstract 
who write as if they never thought of it. In fact, the scholastic style of the 
lecture-room is not a whit better. So that the student, who does not have the 
chance to change off at the clinique his second-hand stock of notions obtained 
from the anatomical pathologists of the college, gets a wrong start in life. He 
may gaze at highly-coloured plates, and bad smelling specimens in transparent 
jars, and think he sees there the inheritance which falls to all flesh, disease 
itself, body and spirit. So that he secure the pearl what matter how the 



1858.] 



Gross, Elements of Pathological Anatomy. 



149 



oyster sickened ! He starts up, and bunts out quantities of monstrous spe- 
cimens and rarities, and does not find out that they may be worth to him 
no more than so many coffins, till the granting of a license to practice medi- 
cine lets him down to the clinical common places, which pathological anato- 
mists, by profession, have either ignored or shown to him through a darkened 
glass, darkly enough. He has groped "with greedy hand for treasures, and 
exults at finding earth worms/' Instead of the animated nature, he has, like 
Faust, " naught around him but beasts' skeletons and dead men's bones in 
smoke and mould." 

These anatomists are like some numismatologists. One man finds pleasure 
in collecting, polishing, and arranging all the medals of all the ages. But 
though he should find them all, and know them all by sight, and call them all 
by name, put each one into its own place ; though he should measure, and 
weigh, and value, and burnish all the coins of every die, they might be of no 
more worth to him than so much brass. Let him read dates and inscriptions 
with all pedantry, his cabinet would be only a junk-shop, if each little medal 
did not teach him whole chapters of history, facts, and philosophy, poetry, and 
the arts of war, designing, engraving, die-sinking, in a word, the genius of the 
people whose signum it has been. 

What a pity that dead men tell no tales. Hollow skulls are supposed to 
have said something to St. Jerome, and to Oken and Owen, but, in some com- 
pany, they are as silent as they are sightless. An anatomist has a skeleton 
in the house, and a vitalist is overrun with spirits. Each of them has effected 
%vgi$ xai %u>pio[xo$ tyvxys <*7t6 flea/tar 1 oj, but neither has a man. 

The basic-idea or philosophy of Dr. Gross's Elements of Pathological Ana- 
tomy, is plainly enough indicated by the following passages which we pick out 
from their contexts, and expose as independent propositions :— 

I. u All organic diseases, whatever be their seat or extent, are the result of 
inflammatory action.'' 

II. " Every inflammation, irritative or morbid action, is originally of a 
local nature." 

III. u It may be doubted whether under any circumstances there can, strictly 
speaking, be a functional disease without some change in the anatomical ele- 
ments of the part." 

It is our purpose to present a detailed exposition of these axioms as they 
have been applied by Dr. Gross to the different organic lesions and elements 
of disease in their author's own words, and in accordance with his arrange- 
ment, as far as is possible. The plan of his book consists in the consideration 
of the general principles of pathological anatomy, including inflammation, 
transformations, tubercle, cancer, &c, occupying the first two hundred pages; 
followed by a very full and satisfactory application of these principles to all 
the organs and tissues, beginning with the blood and proceeding from the 
cellular tissue through the muscles, bones, &c, of the adult to the placenta 
of the foetus.. 

The completeness of this work, as regards the subjects treated, is especially 
admirable. But, en revanche, many subjects are necessarily slurred, and some 
but dimly hinted at. It is, in short, as encyclopaedic as the lectures of a 
practised, popular, and fluent professor of surgery are likely to be. It is like 
reading a dictionary or gazetteer. The time has gone by when one man can 
be competent, or live long enough to travel all over the medical cosmos and 
describe its wonders in one volume, even though the book pretend only to 
treat of elements. By elements should be understood first principles — and 



150 



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[Jan. 



not a catalogue resume of the titles in brief of all the remarkable facts and 
phenomena that ever were heard of. We might as well expect to enjoy the 
scenery of a country by reading a conveyancer's abstracts of titles to its real 
estate, as to find substantial profit in such compact enumerations of anatomical 
splendors. 

The book is opened with a short and general review of the facts of normal 
anatomy. These opening paragraphs, brief as they are, we find to be charac- 
teristic ; being shaded by a dark hue of materialistic, or rather mechauico- 
organic morbid anatomy, which we enter protest against here in advance. 

The human body (chap. i. p. 33) is composed of solids and fluids. Of the 
fluids the blood is the most important, although Dr. Gross does "not feel dis- 
posed to attach that great importance to it which the advocates of the old 
humoral pathology did." The solids consist of tissues, which, combined in 
various ways, constitute the organs, whether parenchymatous, pulpyQ.), glan- 
dular, or erectile. 

Connected together by vessels and nerves, as well as, m some instances, by 
continuity of surface, there subsists between the various parts of the body, 
the closest felloiv-feeling. After allusion to various examples of " sympathy," 
our author continues : "I have thus briefly adverted to the relationship sub- 
sisting between the principal organs of the body, and endeavoured to account 
for it upon anatomical principles." One might as well attempt to explain on 
known anatomical principles the contractions of the uterus after nine months' 
gestation, or the evolution from a Graafian vesicle once in four weeks. No hint 
is here given of an incipient conception of the idea of an unseen pervading 
power or property, which makes of a community of molecules, of myriads of 
active agents, having a certain independence, a single larger being of a com- 
pound and complex organization. But as the author doubts whether the dis- 
cussion of this subject (sympathy) would result in good, we proceed, objecting 
here only to the dictum which he throws in as a plea for evading the question. 
He says: "What is most worth knowing is soonest learned and least subject 
to dispute." Then have nurses and practitioners of the routine school the 
advantage over those who practise experimental physiology, and study the 
general laws of life. The statement would not be seriously noticed, if it were 
not apparent throughout his book, that Dr. Gross attaches an exaggerated im- 
portance to the outside and measurable characters of morbid specimens, and 
undervalues to the same degree, or ignores the subtle impalpable psychological 
influences which really give the character to a particular disease. Do not the 
anatomical characteristics of a local manifestation of disease vary with its dia- 
thetic character? Are ordinary pneumonia, an inflammation of the lung from 
a fractured rib, and an inflammation of the lung preceding a manifestation of 
gout in the limbs, to be described as identical? Taking a step backward, let 
us inquire with Dr. G. " what constitutes disease, for everybody knows what 
is meant by health" — excepting those, we may interpolate, who agree with 
Vogel, that u il n'y a pas oV organisme humain qui off re V ideal de la sante dans 
toute sa perfection" * * * * (Jourdan's Trans.) Disease may be defined to 
be a departure from the sound state, whether this departure consists simply in 
a derangement of function or structures." [That is brief and clear.] "So long 
as the solid and fluid materials of the body act in concert, health must be the 
result, but ivhen the blood and the tissues are arrayed as it were against each 
other, there is disease." We have heard of disturbances of molecular attrac- 
tion, and perversion of nutrition, but the latter part of this definition bears 
more resemblance to the following, taken from a recent work on General 



1858.] 



Gross, Elements of Pathological Anatomy. 



151 



Pathology. "Disease is a common accident, appertaining to the organization, 
which, like the words life and health, is altogether indefinable." 

We are curious in .matters of definition, and enjoy a good one ; we shall 
put this in our collection. From a recent work on Pathology we extract the 
following definitions de la maladie, as illustrating the philosophies of medi- 
cine that have had sway, and the oscillations of the sacred faith from the 
vitalism of Sauvages, in whose eyes a malady was the "reaction of the interior 
vital principle against deleterious agents," to Buffalini's materialism, which 
held disease to be a " change in the material condition of the body." 

Thus we have at hand an epitome of the history of medicine, from Van 
Helmont, who saw in disease only the results of disturbances occasioned by 
the grand Archceus (a puissant dignitary who held court-chambers, in the 
neighbourhood of the cardiac orifice of the stomach) all the way down through 
the ages to that dreadful field where the tissues find themselves pitted against 
each other in bloody array. [Gross, p. 36.] But in our retreat to quieter 
times, we learn that Hippocrates considered disease to be the sum of phe- 
nomena, resulting from the reaction of the conservative principle of the organ- 
ism against an impression of evil or injury. 

Stahl was of the same opinion, for he defined disease to be an effort of the 
anima to re-establish an equilibrium of the normal functions, and to expel 
injurious agents. 

Sylvius de Libae, professor at Leyden about 1650, told his pupils that dis- 
ease was a simple lesion of the functions of the living body. 

Sydenham believed disease to be an effort of nature, set up for the patient's 
relief, and the destruction of morbific matters. 

Frederic Hoffmann (Halle, 1660 to 1742) called maladies efforts or struggles 
with death — conatus moriendi. 

Brown, the man of "Excitability" (1736 to 1788), thought that disease 
should be treated as a "painful, difficult, or irregular exercise of one or more 
functions." 

Reil, J. C, Professor at Berlin (1759 to 1813), regarded disease as a 
" peculiar action of the organization which replaced ordinary operations when 
disturbed by unusual circumstances, by an operation altogether new." 

Broussais' famous dictum was to the effect that disease was nothing but the 
effect of functional irregularities. 

Cayol taught that disease was a function, destined to react against disturbing 
causes and the destruction of the living body. 

Dubois d' Amiens (Sec. Perpetuel de FAcademie de Medecine) proclaims 
that maladies are lesions of innervation which produce secondary organic or 
structural lesions. 

We have thus founded a formidable opposition to the doctrines of the mate- 
rial localization of diseases, whose advocates, however, make a fair show of 
hands, stretching from the earliest times to this present day. 

Asclepiades (about b. c. 70) heads the list, with the doctrine that disease is 
an unnatural state produced by the irregular motion of the atoms. 

Themison found in all maladies only tension or relaxation of the fibres of 
the body. 

Galen, with a sharp insight, but inconsistent rhetoric, endeavored to explain 
how disease had its point of departure in a structural lesion, although no dis- 
ease could really be said to exist except in a lesion of function. 

For another, "disease is a peculiar state of the body resulting from a super- 
abundance or from a deficiency in the quantity of fluids, or some change in 
their relative proportions." 



152 



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[Jan. 



Frederic Hoffman described disease as being a disproportion or irregularity 
in the natural order of movements, whether general or partial. 

Among the aphorisms of Boerhaave we find this : Disease is a structural 
change which deranges the vital, natural and animal functions. 

From Fernel we learn that disease is an alteration of the blood, humors, or 
spirits, which occasions structural changes. 

It may justly be said that these definitions render no account of the numer- 
ous dynamic maladies which present no demonstrable alteration of structure 
•or modification of fluids. 

The following are representatives of the compromising organo-vitalistic 
doctrines which include in their definitions both the dynamic elements and the 
material elements of the organization. 

G-aubius, of Heidelberg, 1768, taught that " disease was a condition of the 
living body, which prevented the exercise of those functions which were 
proper to a state of health." 

Chomel covers broad ground when he says la maladie est une alteration nota- 
ble survenue, soit dans les dispositions mater idles des solides ou des liquides, soit 
dans l' exercise d'une ou plusieurs fonctions. 

Andral describes disease as an alteration of the constituent parts of the 
body and of the functions appropriate to them. 

Bouchut defines with brevity, " diseases are transformed impressions." A 
disease is then a disorder of the forces and of the parts of the body, and of 
the functions local or general. 

As a knowledge of disease implies a knowledge of health, so Pathology im- 
plies a knowledge of Physiology and Pathological Anatomy, which treats of 
all the disorders of which the organization is susceptible, from the immediate 
principles to the organism considered in its indivisible totality, and involves an 
acquaintance not only with (a) Anatomy, (b) Physiology, but also with (c) the 
science of Media, or the external agents which surround the body, and in- 
fluence its functions — 

Wer sie niclit kennte 

Die elemente 

Ibre kraft 

Unci Eigenschaft, 

Ware kein meister 

Ueber die Geister. 

To gain the knowledge of the earth, one man walks all over its surface, 
and another bores Artesian wells; but when they have done they must both 
go to the dog-star to find out the secret of this little ganglion of the universal 
solar plexus — they must study through the great and little world. Some one 
has said, "For the phenomena of life, we want the whole concourse of nature." 
The pathologist, who only interrogates death for what can be learned concern- 
ing life, must be prepared to range over the whole circle of the sciences. 
What is life? Says one, "Life is the sum of the functions by which death 
is resisted." The metaphysician sees in life " the result of organization '." 
For another mind, life is the principle of individuation. 

The definition accepted by the school whose characteristic views we are 
endeavouring to represent, is the one proposed by De Blainville, as follows : 
" Life is the twofold internal movement of composition and decomposition, at 
once general and continuous." 

" This," says Comte, " is the only definition capable of fulfilling all the 
multifarious conditions required. It presents the exact enunciation of the 
sole phenomenon rigorously common to the ensemble of living beings con- 
sidered in all their constituent parts, and in all their modes of vitality. 



1858.] 



Gross, Elements of Pathological Anatomy. 



153 



A man, sick or well — which qualities are only relative — is to be considered 
with regard to his static and his dynamic condition; all his organs, all their 
actions or properties, and all the media which surround and affect him, are to 
be known. 

The English school was at one time looking at this matter of " the sur- 
roundings," as those who remember Connelly's lectures in London must be 
aware. But the microscope has now made everybody near-sighted, and in 
setting them at little things, has let them forget the greater. But that is not 
the fault of the microscope, as it is not a fair charge against the speculum that 
men endeavour through it to cure a general disorder by the topical application 
of the solid stick. 

What, in life, is disease ? It is not merely organo-pathic states, which can 
be materially appreciated by the senses — but these and something more; 
these are material effects, or rather a part of the chain whose beginning at- 
taches to a primal disturbance of the forces which preside over the growth 
and development of individual anatomical elements, and binds them into a 
complex unit. 

The assertion of Agassiz is undoubtedly true, that the most complicated 
combinations of structure and adaptations can be rendered independent of the 
physical conditions which surround them; but it is also true that in their 
progress towards a state of toleration of their new circumstances, especially 
if the change be sudden, they are likely to present temporary manifestations 
of disease. It is curious to note here the illustration to the statement that 
Pathology is following in the footsteps of Anatomy, but afar off — so far be- 
hind, indeed, that the latter has forsaken a stand-point just as the former ar- 
rives on the ground. Thus Agassiz (Contributions to Nat. Hist, of the U. S., 
vol. i.) announces that to assert the dependence of structural peculiarity upon 
climatological conditions is an unsound dogma, just at the time when patholo- 
gists are beginning to question the media with more rigorous severity as being 
among the chief causative elements of disease. 

Pathological Anatomy cannot be separated from Pathology, and Dr. Gross 
has not succeeded in divorcing their union, though he seems to have tried 
with intermittence. Pathological Anatomy, in the narrow and limited sense 
in which it is taken by some writers, is rather a subject for iconographic re- 
presentation than for verbal description. 

Following our author, we come now to the consideration of the chief of all 
the morbid, actions, inflammation. We call this the chief, as does Dr. G., 
but it seems to be implied, in some parts of the book, that inflammatory action 
is the only morbific action; that inflammation is, in fact, the only disease. 

This opinion differs so entirely from our own, that we would prefer to ex- 
punge the word altogether from the medical glossary, or limit it within the 
bounds to which fever and irritation have been reduced. If inflammation 
means everything, it describes nothing ; and is of no more utility as a means 
of defining a state or result, than is the word disease. 

The difficulties of expressing a correct definition of inflammation are recog- 
nized by all recent writers, and specially noted by those who use the word 
with restrictions. But neither stasis nor hypersemia — words suggested as 
synonymous with inflammation — express all the phenomena belonging to that 
complex disturbance of functions, and alteration of structure, recognized as 
inflammatory. As we have said, we do not like the word inflammation, and 
would be glad to find good substitutes for it; but there 1 are very many ob- 
jections to pulling out a word so firmly fixed as that has become. We do not 
like it, because it is suggestive of a uniformity and identity of processes and 



154: 



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[Jan. 



results in connection with phenomena which have no common essentials. 
Wherever it is possible, let there be used specific phrases which indicate with 
more exactitude the particular constitutional or general element — as whether 
(a) inherited or acquired; (b~) its dyscrasic character — scorbutic, syphilitic, 
scarlatinal ; (c) the locality ; (d) the results — as exudations, softening ; (e) as- 
sociated disturbances of function. 

It is not proven, nor is it probable, that a phlegmasia process arising from 
an internal cause, bears any resemblance to an inflammation produced arti- 
ficially. A drop of cantharides and a tadpole's tail cannot, by any possible 
conjunction, enlighten us on the subject of mumps, lung-fever, or boils. 
Everybody agrees to that, even those who go on in the classical way, talking 
about redness, heat, pain, and swelling. The reformation of nomenclature 
will lead to more truthful and exact notions of the phenomena if expressed 
in scientific terms of definition. For some maladies and classes of disease, 
the change has been already effected. Thus, we do not lump together herpes, 
pemphigus, psoriasis, and porrigo. The ignorance or carelessness of desig- 
nating a squamous sypliilide with so little nicety as to call it an inflammation 
of the skin, would be considered quite inexcusable; but no more nicety is 
shown in the designation of the great majority of similar internal manifestations 
of disease which are all called by the generic name inflammations. What es- 
sential resemblance is there between gonorrhoea and bronchitis ? The inde- 
tectible poison of the one and the butyrates of the other, are alike overlooked 
by those who see in these diseases only examples of common inflammation of 
mucous membrane. A gouty enlargement of a great toe, and a whitlow of a 
finger phalanx might, without inconsistency, be regarded by some pathologi- 
cal anatomists as effects of identical processes; but in real differential charac- 
teristics they are as far apart as are the two extremities of the body. The 
whole of rickets is not told in Virchow's masterly description of softening 
bones ; dysentery is not merely an inflammation of the lower bowel ; cholera 
infantum is more than an inflammation of glandules in the small intestines ; 
and just as epidemic catarrh is more than an inflammation of the faucial and 
bronchial mucous membranes, and typhoid fever more than inflammation of 
Peyer's patches, so is intermittent fever more than inflammation of the spleen, 
and the cerebral disturbances of scarlet fever more than intra-cranial inflam- 
mation. Everybody says amen— but in everybody's books these simple 
truisms do not appear with the emphatic distinctness which they might claim ; 
and by such faults of omission and commission of the treatises which should 
give sound principles, and ready method rules for the prompt and intelligent 
treatment of the sick, but do not give them — by such faults, the student finds 
his unsound principles as much in his way when he comes to sit down at a 
bedside, as a long broadsword would be. 

It is because we are ill satisfied with the imperfect teachings, and fear the 
dangerous errors of classical morbid anatomy, that we do not share Dr. Gross's 
regret that in the forty-five medical colleges of the United States, there are 
but few chairs of Pathological Anatomy; and we certainly cannot regard this 
destitution of our schools as attributable to a " strange and culpable over- 
sight." Let us have all the Professors of the Theory and Practice of Medi- 
cine which the number of students in each college may warrant — and as no 
one man can have time, strength, capacity or cultivation to teach the whole 
science well, let there be special teachers of special branches; and let each 
one begin at the ultimates, and make a complete development from the radi- 
cles of physics to the efflorescence of vitalistic speculations. 

Some of the best expositions of Pathological Anatomy extant are contained 



1858.] 



Gross, Elements of Pathological Anatomy. 



155 



in clinical lectures on special subjects; and this is the way we desire to have 
medicine taught, with its anatomy, pathology, and therapeutics of special dis- 
eases simultaneously presented. 

The lectures on special subjects in the hospitals of our large cities do more 
good to advance Pathological Anatomy than chairs of Pathological Anatomy 
or systematic treatises are likely to, for the reason that the former approach 
the subject from the right direction. 

Towards the removal of erroneous and imperfect notions of morbid pro- 
cesses, much progress would be made by a reformation of nomenclature. 
Very simple terms may be used. In these anti-classical times it is not worth 
while to dig with Piorry too deeply for Greek roots. Let there be, as far as 
possible, a plain statement of the organic changes and vitalistic disturbances. 
For inflammation, substitute in most cases the word disease, and express, 
after the various localities have been mentioned, the specific process, whether 
simple or complex, as exudation of lymph or serum, &c. ; with the qualifica- 
tion then of the peculiar dyscrasic condition, as scorbutic, diphtheritic, scro- 
fulous, and their mutual relation to the derangements, as primary or second- 
ary. We shall have, in most cases, not only a plain scientific designation of 
the morbid processes, but also such a full description of the case contained in 
the enumeration of the elements of the disease that very little more need be 
added in reporting cases to render them fit to be tabulated. " We may learn 
the essence from the name." 

The following case may illustrate the design of these remarks. 

A middle-aged lady, with a solid ovarian tumour of many years' growth, 
had a chill when resting by an open window after a brisk walk. She con- 
sidered herself in full health at the time, and was so in appearance. She had 
the same day pain in the abdomen, followed by constipation, which lasted 
eleven days; then a low form of fever for six weeks without disturbance of 
the bowels, and without any marked symptoms except watchfulness; then 
repeated chills, or chilliness with imperfect reaction for two weeks; a cough 
for two days; dulness on percussion of right side and entire absence of respira- 
tory sound for one day, at the end of which abundant sweating, failure of 
pulse, and death. 

Post mortem examination revealed superficial layer of fat, thick; bed-sores 
partially healed; right side of the thorax full of water, clear, without fiocculi; 
pleural surfaces clear, shining, smooth, without redness or adhesion; no ves- 
tiges of false membrane anywhere; every other part of the body healthy in 
appearance except pelvis and lower part of abdomen; here was a tumour 
weighing ten pounds, twisted on its ligamental attachments, so that its veins 
were compressed and its surface mottled with distended vessels. A knuckle 
of intestine had been compressed by false bands, but had got loose. There 
were no signs of secondary exudative processes about this tumour, excepting 
for the space of one inch in a large vein on its surface, where there was a red 
coagulum with thick creamy looking fluid. From the Fallopian tube of that 
side a little muco-purulent fluid oozed out. 

What was the disease, and how to express it? Ovarian tumour; arrested 
transpiration of skin; disturbance of bowels; strangulation of intestine; hy- 
peremia of tumour; suppurative disease of vein ; pyaemia; hydrothorax — this 
enumeration is needed to give a name, but its titles, like those of some other 
things, include all there is of it. It is interesting to notice that one of the 
obvious and striking phenomena here for the anatomist, viz., dropsy of the 
chest, did not occur till within the last two days, and was not accompanied at 
the time of the examination by either redness, loss of polish, or fibrinous exu- 



156 



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[Jan. 



elation of the serous surface. The classical signs were wanting, excepting hy- 
drothorax, and this, according to Laennec and Forbes, if it were not an inflam- 
matory production, was indeed a rarity. There are many cases in which, as 
in this just described, there are several associated phenomena, primary or se- 
condary, which pathological anatomy should make note of, if it can offer no 
explanation of the alliance. For example, the spangemia, hysteria, and disease 
of glandules of fauces associated with induration and ulceration of the os uteri. 
If it cannot explain or does not try to explain the association of redness of the 
eyelids with spermatorrhoea; the occurrence of itching of the nares from intem- 
perate coitus, or the occasional dependence of intercostal submammary pain 
upon tobacco poisoning, and scores of acknowledged but unseen bonds of union, 
it must be warned not to promulgate such false principles concerning the uni- 
form character of inflammation and the universality of its presence at the 
bottom of all morbific actions, as to mislead in regard to the diagnosis of such 
consociations and their consequent treatment. It must not by any represent- 
ation concerning inflammation teach us to treat a rheumatic disease of the eye 
as if it were catarrhal. Nobody means with deliberation, to face out blun- 
dering of that sort, but such instructions are sometimes given unwittingly, 
and rather by implication than by downright statements to the same effect. 

;js Jfc jfc 

But to proceed, under our author's guidance. In the general exposition of 
inflammation, Dr. Gross makes a very clear and comprehensive statement of 
most that is known to be "real and substantial" in regard to the progress, 
intensity and mode of termination of this disease. Under the head of Eti- 
ology, the modifications associated with temperament, age, sex, habit, climate 
and season are considered as well as the specific characters in relation to the 
textures affected, and the predisposing cause. 

Under the head of Phenomena and Nature of Inflammation the signs 
usually enumerated as marking inflammation — discoloration, heat, pain and 
swelling are mentioned at some length, and Dr. G. remarks that " they are 
not always present, nor are they the only circumstances which occur in inflam- 
mation in this disease : [what disease ?] in every case there is a perversion of 
the vital actions attended with an altered state of the nutritive and secretory 
functions:" and our author continues, "if we regard these four phenomena 
as essential to the process there can be but few inflammations." We must 
therefore invoke other names, such as irritation and fever. But Dr. Gr. objects 
to these words because "they do not describe the peculiar conditions of the 
nervous and vascular systems. Yet men continue to talk about irritation as 
if they had the most perfect knowledge of its seat," &c. If he had included 
inflammation in this indictment it would have been no injury to the cause of 
justice. 

In speaking of temperature reference is made to certain experiments of 
Huber, Dunglison, Everard Home and Hunter, tending to demonstrate that 
the temperature of an inflamed structure is higher than that of the blood. 
But no reference is made to Bernard's experiments or Brown-Sequard's state- 
ments. When speaking of pain Dr. Gr. says: "The degree of suffering evinced 
by the mucous membranesQ.) in a state of inflammation is subject to much va- 
riety, which may be perhaps explained by the fact that while some portions 
are supplied by the ganglionic system, other parts derive their nervous filaments 
chiefly from the cerebro-spinal axis." Many examples are given of "perverted 
vital action" and altered function, which are well enough put; but we should 
like to ask if those who have followed our author do not find enough, in addi- 
tion to the evidence which the preceding descriptions furnish, to convict this 



1858.] 



Gross, Elements of Pathological Anatomy. 



157 



inflammation of false pretences and have him banished forever — for he is 
indeed a bad fellow — a consumer of nutrient substances, and an incendiary. 
But he pretends to light fires for household economic purposes — to cook, to 
prepare nutritious materials, to heat glue for adhesion, and generally to repair 
damages. He deserves no such credit : there is a great amount of repara- 
tion going on without his assistance. The fact is, whatever he undertakes to 
do he damages. But, on the other hand, he is not to be made a scapegoat of. 
There is a deal of mischief done when he is not by. 

In considering the seat of inflammations, the state of the capillaries, altered 
absorption and nutrition, the relative agency of the vascular and nervous sys- 
tems, good use is made of the published investigations of Virchow, Henle, 
Bennett, and Wharton Jones. What is known from them is compactly and 
circumstantially stated. 

Dr. G. still hangs on to the terminations, but we are disposed to cut 
them off altogether. Instead of saying there are seven terminations of 
inflammation: 1, resolution; 2, effusion of serum; 3, deposition of lymph; 
4, suppuration; 5, hemorrhage; 6, softening; 7, gangrene; let these pheno- 
mena be described with all the minuteness possible, as so many manifestations 
of disease. It does not assist us to their better acquaintance to call them in- 
flammation — and destroys the chance of standing upon a common therapeutic 
basis. How much better, said Bichat, " inflammation terminates by, 1, re- 
solution; 2, repercussion; 3, suppuration, or by other diseases. 

Following Dr. Gross's classification we come to — 

Effusion of Serum. — Dr. G. doubts whether oedema or anasarca occur, 
without inflammatory action, and reasons in this manner (pp. 61, 62) : "It is 
frequently extremely difficult to ascertain the condition of the seat of the ef- 
fusion by anatomical inspection. In ascites, how often does it happen, that 
there is the most copious accumulation of water, caused obviously by inflam- 
mation, and yet, on examination after death, there is scarcely a single trace 
of the latter malady. The absence of redness does not prove that there was 
no inflammation, for the discoloration with other signs often vanish, just be- 
fore death. Effusion from mechanical obstruction cannot exist without pro- 
ducing a state of parts analogous to" (what state is then analogous to, and yet 
not inflammation?) "if not really identical with inflammation. But it may 
be said, that the effusion may result from perverted action, from irritation 
or distended function, all this may be true and yet not in the least invalidate 
our position. Everybody knows that in inflammation there is perverted ac- 
tion, or deranged function with irritation or altered sensibility." Poor rea- 
soners — like good navigators — stick to the great circles. Once more he 
says: "In the same manner, hydrothorax is sometimes induced by tubercles 
of the lungs; hydrocele by carcinoma of the testicle; hydrocephalus by heter- 
ologous growths of the brain. In all these instances, effusion of water is 
the result unquestionably, of inflammation lighted up in the serous covering 
of the respective organs by the morbid deposit acting as a foreign substance." 
In whatever relations the morbid deposit and the inflammation may stand to 
each other, we would rather regard the diathesis which has produced the 
solid growth to be a good and sufficient cause, proximate and remote for the 
dropsy. And again : " The dropsical accumulations which supervene upon 
scarlet fever, measles, and other eruptive diseases, can be traced in most cases 
directly to phlegmasial irritation of the serous membranes." We think this 
bad pathology which would be likely to eventuate in worse therapeutics. 
The convulsion, coma, sore throat, desquamative disease of kidney, albuminu- 
ria, and dropsy of scarlet fever, are no more the signs of local inflammation, 
No. LXIX.— Jan. 1858. 11 



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[Jan. 



or any such process, as the frozen ear of a rabbit illustrates, than is the scar- 
latinal redness of the surface due to an inflammation of the skin. We would 
not call a variolous pustule an inflammation of the skin, though Piorry says 
it is nothing but an abscess. But the definition of inflammation which really 
defines, is to be the work of the Coming Man. 

" Lymphization." — A term not found in any other pathological treatise, as 
Dr. Gross confesses, is the heading of another chapter, The effusion of fibrin 
is invariably of inflammatory origin, and is often the only sign of inflamma- 
tion existing after death. Lymph is defined by Dr. Gross as a vital organiz- 
able substance separated from the blood by a process of secretion. It does 
not always exhibit the same appearance. When first exuded it is semi-liquid, 
but its consistence thickens, and it may become organized and transformed 
into tissues. An excellent description of the microscopic appearances is 
given (p. 64). Of the inflammatory globule of Gluge,«it is said that it is 
not confined to inflammatory lymph. Mention is made of Rokitansky's divi- 
sions into croupous and plastic, and Paget' s into fibrinous and corpuscular, 
and the various intermediate varieties, but no allusion is made to Virchow's 
admirable researches on the nature and properties of fibrin, contained in 
various papers published since 1845. An omission somewhat remarkable in 
this connection, inasmuch as this subject has been for some time regarded as 
the specialty of the Wiirzburg professor. 

" The chemical composition of lymph proves it to be similar to the buffy 
coat of the blood. It is effused under a considerable variety of forms de- 
pendent upon the shape of the part which supplies it." This is a variation of 
form which is not of the slightest consequence. Concerning the rapidity 
of the formation of the plastic exudation, Dr. G. says it may form within an 
hour and to a considerable amount in four hours, and a case is given in illus- 
tration. Lymph tends to become organized, and becomes supplied with ves- 
sels either by the vessels of the natural tissues shooting into it ; or sponta- 
neously by powers residing within itself. 

This process is traced up, to the development of fibrous tissue, with the aid 
of figures of cells and fibres, after Bennett. 

" Plastic lymph organized, forms the basis of all the analogous tissues and 
the bond of union of divided parts. It may become the seat of inflammation 
both acute and chronic, pour out serum, lymph, pus, and even blood; and 
undergo the same transformations precisely as the natural textures. It is, 
likewise, the source of what is termed induration, and probably, also, in a 
modified form, of scirrhus and tubercle." These statements are like many 
other wholesale statements. They contain a great deal of verbal outside 
fact with a little inner falsity — just enough to spoil them and make them 
dangerous. 

" The analogous tissues, formed out of the plastic element of the blood, are 
nearly as numerous as the natural tissues; thus, cellular, serous, mucous, 
cutaneous, vascular, adipose, horny, epidemic, fibrous, fibrocartilaginous, car- 
tilaginous, osseous. 

" Coagulating lymph performs a conspicuous part in the reunion of divided 
parts. Without its agency, ulcers would not heal, and fractured limbs would 
dangle about " in wild uncertainty." By this is produced union by adhesive 
inflammation. What should we do without it? It is to be hoped that we 
are all in a comfortable state of inflammation. If so, we are as well as could 
be expected. 

It is our belief that the term adhesive inflammation does not express a fact. 
Suppuration. — "This is the third mode by which inflammation relieves it- 



1858.] 



Gross, Elements of Pathological Anatomy. 



159 



self. Pus is never deposited where there is an entire absence of inflammation. 
A cold abscess is the result of inflammatory action quite as much as a phleg- 
monous boil is. Pus, may be formed without a solution of continuity. It is 
found much more readily and abundantly in organs which contain the largest 
amount of cellular substance." 

This is all very well, but hardly serves as a fit introduction for an article 
on suppuration, which is intended to be up flush with the times, and so placed 
as to reflect the light which Yogel and Wedl have shed on this matter. What 
follows is much better. The consideration of abscesses, and especially the 
paragraphs which treat of the nature, varieties, and tests of pus, leave hardly 
anything to be said. This chapter resembles some others in being extremely 
unequal in style and scientific method. 

Chap. Y. Hemorrhage. — There can be no doubt that this chapter is en- 
tirely out of place in occupying a position between suppuration and softening, 
but we defer the suggestions on classification which we wish to make to an- 
other place. After noticing the uncertainty of our opinions on this subject, 
Dr. Gross remarks that, formerly, the idea prevailed that all sanguineous effu- 
sions depended upon rupture of bloodvessels; and adds, nor is this notion 
yet eradicated from the minds of some. It is not to be denied that most of 
the good books recently published give evidence that such an opinion is by 
no means entirely eradicated from the minds of the best pathologists. Our 
author has no faith in exhalants, and devotes to these mythical structures a 
paragraph or two. But he believes that the capillaries, being in a state of 
debility and relaxation, have their pores rendered unnaturally patulous, and 
thus allow the blood to have a more ready egress. Relaxation and Pores. — 
"It is precisely where meaning fails that a word comes in most opportunely." 
This process takes place within the limits of health (it is gratifying to know 
that there is something that can take place within the limits of health), as in 
the uterus where it constitutes the menses. The other subjects treated of in 
this chapter, are the liability of different structures to hemorrhage, the causes, 
the effect of inheritance upon it, vicarious hemorrhage, and the classes into 
which hemorrhage may be divided. Under the head of changes in the effused 
blood, it is said that the blood may be rejected, absorbed, may remain and 
become organized, or may act as a foreign substance and produce fatal inflam- 
mation, and, finally, may undergo various changes in colour and consistence. 
This is an interesting subject, and entitled to longer consideration. That 
effused blood ever becomes organized may reasonably be doubted. 

Softening. — "One of the most singular effects of inflammation. The 
term is synonymous with that of mollescence(l), so much in vogue among the 
French pathologists. All parts are not equally subject to it. The parti- 
cular anatomical element in which the changes are most marked is the inter- 
stitial cellular. Cadaveric softening may induce mistakes. Its differential 
characteristics are not, however, given in this place. There is a species of 
softening in the nervous centres dependent upon closure of the arteries. This 
interruption of the circulation, however, interrupts nutrition ; but it is not 
by any means clear that 'the changes which the organ experiences are not of 
an inflammatory character/ The bloodvessels in many cases seem to have 
entirely disappeared, whilst in others they are so weak as to be incapable of 
withstanding the slightest pressure or receiving the finest injection. There 
can be no such thing as dry softening." 

Softening of the heart is well described. It may co-exist with phthisis, 
pleurisy, typhoid fever, or take place as an independent affection. The micro- 
scopic appearances are not given by Dr. G. The subject (softening) is one 



160 



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[Jan. 



of very great interest, and deserves treatment at length, being, perhaps, the 
most common and widely distributed of all organic lesions. 

The experiments of Hamont and Levret upon the blood in malignant pus- 
tules are spoken of. It may be mentioned, in this connection, that different 
forms of carbuncle and furuncular diseases with ecthyma have prevailed to an 
increased extent in some of the large cities of this country during the last two 
years. And it has been pretty well established, that Dr. Locock's opinion 
concerning their contagiousness is founded on fact. 

Gangrene from ergotism is treated at some length. Of the modus ope- 
randi of this agency we are ignorant. It probably affects first the blood, and 
then "the capillaries, causing inflammation in them followed by gangrene — 
the nervous system is, no doubt, also seriously involved; all that is contended 
for, is, that these are the parts which receive the primary impression what- 
ever that may be." The scepticism which calls this agency in question is very 
reasonable. 

Ulceration may be defined to be " the molecular death of a part." " Of 
the intimate nature of this lesion nothing is known, with any certainty, be- 
yond the fact that it is essentially connected with inflammation." "The cuta- 
neous, mucous, and cellular tissues are much more frequently affected than 
all the rest put together. This is well exemplified in the numerous blotches 
which so often cover the body, and in the erosions which are so frequently 
noticed in the bowels, mouth, throat, vagina, and larynx. The liability to 
this affection varies very greatly even in parts of the same structure ; thus, 
1 for one erosion of the stomach we find at least a thousand in the ileum/ " 

" Ulceration always manifests a tendency to extend towards the nearest sur- 
face." The great cause of ulceration is inflammation conjoined with pressure. 
The caries of bones produced by the pressure of an aneurism "disproves the 
idea formerly so current that ulceration can never happen without the forma- 
tion of pus." 

What is the nature of the concomitant inflammation? The assumption is, 
that it is specific, that it is modified by circumstances, local or general, or both 
combined, which the pathologists cannot appreciate. 

The subject of ulcers, in the second part, is excellently treated. But we 
think that Dr. G. seems to consider a collection of processes, or a compound 
one, as a single and simple one. 

Ulceration may be a salutary process, a means employed by nature to rid 
the animal economy of extraneous materials, collections of purulent fluids, 
bullets, and tubercles. " In old drunkards it seems to be designed to relieve 
the system of hurtful fluids, by establishing extensive sores on the legs, 
attended with a perpetual flow of irritating matter. Thus we see that 
ulceration, although apparently a very unpleasant, is ; in many instances, a 
most fortunate event, and one for which the practitioner often anxiously looks." 
This chapter, though containing many good things, is very imperfect. 

Granulation. — "This process is one of the grand operations, employed by 
nature for the cure of wounds and the filling up of ulcers. A granulation is a 
vascular body, consisting at first essentially of coagulating lymph. In this an 
arterial and a venous branch — a small nerve and an absorbent, probably — are 
developed. It is thus an absorbing as well as secreting body, and performs 
the triple office of pouring out lymph, secreting pus, and absorbing such sub- 
stances as are brought in contact with it. The concomitant inflammation 
appears to be of a mixed character, as it is attended with the' simultaneous effu- 
sion of lymph and purulent matter.^ We are getting befogged. This Pro- 
teus appears in more characters, on the same occasion, than the infant phe- 



1858.] 



Gross, Elements of Pathological Anatomy. 



161 



nomenon — one kind effuses lymph and another pus. We had hoped that 
granulation would heal the old sore; we look hopefully at the next chapter. 

Chap. X. Cicatrization " It is the finishing stroke, if the expression be 

allowable, of granulation — the labour necessary to polish the surface of the 
sore, to contract its diameter, and to bring it as nearly as possible to a level 
with the surrounding structures" — and it is expected to be up to the scien- 
tific level of the times. 

"This process is not limited to the skin. The first step in the process of 
healing is the subsidence of the inflammation. The granulations contract and 
coalesce, the surface becomes smooth, the centre being depressed or elevated. 
The first evidence of real cicatrization is a thin pedicle along the breach where 
it unites with the old skin by an interchange of tissue, of vessels and nerves; 
and after the new organized deposit becomes thicker, and extends towards the 
centre by successive experipheral additions of new material." 

Dr. Gross is convinced that ulcers and wounds never heal from the centre ; 
that the process described is the only way by which healing can be accom- 
plished, with the exception of large wounds, which have left little islets of 
sound skin. 

" Are the original textures in the formation of cicatrices always regene- 
rated? Cartilages and muscles are said to be the only parts not susceptible of 
reproduction. But even this is extremely doubtful. At all events, in most 
instances the reproduction is imperfect. There are no sebaceous follicles, and 
no hairs on new skin. Cicatrices are liable to inflammation, contraction, hy- 
pertrophy, and malignant degeneration." 

Induration. — Increase of consistence may arise from the deposition of a 
new product, from a deficiency of the natural secretion, or the transformation 
of the elemental tissues of the organ affected. This excludes all the hetero- 
logous formations. " The causes are referable for the most part to inflam- 
mation followed by an effusion of lymph. In the lungs there is frequently, in 
addition to this, more or less blood poured out, which, combining with the 
natural structures, gives them a red colour. It is thus that red hepatization 
is established." " That induration is susceptible of being cured, daily ob- 
servation abundantly testifies." No allusion is made to more than one kind 
of red hepatization, nor to any other, of Virchow's remarkable discoveries, in 
this direction. There is a pneumonia with granulations and a pneumonia 
without granulations. 

Chap. XII. Hypertrophy. — The title of this chapter is provokingly sug- 
gestive of Mr. Paget' s elegant lectures; but the merits of the chapter lie 
chiefly in the postscript — suggestive of quite another kind of literature. 

Of the causes of hypertrophy some are general, others of a local character; 
of the former, very little can be said to be known. The local causes are 
chronic inflammation, mechanical obstruction, inordinate exercise. 

Hypertrophy essentially consists in an augmentation of the nutritive func- 
tion. The elementary particles are increased in number, or augmented in 
size. In that variety which results from chronic irritation it is not unlikely 
that there is often superadded to the alteration just mentioned a deposit of 
new substance in the spaces of the connecting cellular tissue, leading thus to 
a real change of structure. 

This subject is very defectively treated, both under the head of General 
Pathology and in the detailed application to special organs and systems; for 
example, in speaking of hypertrophy of the uterus, all that we find are the 
following sentences : " Hypertrophy of the uterus, as a result of healthy nu- 
trition, is very rare. The affection is usually most conspicuous in association 



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[Jan. 



with fibrous tumours, in which it is sometimes truly enormous. Thus, in a 
specimen in my possession the walls of the organ are nearly two inches in 
thickness, and of a firm, dense consistence, grating under the knife. Its 
cavity is of extraordinary size, and several small tumors are seen projecting 
from its outer surface. The hypertrophy is sometimes confined to the lips of 
the uterus, which, especially the anterior, become thick, dense, and stumpy." 

We might reasonably expect, in this connection, a description of the coarse 
as well as of the microscopic appearances of this organ in the pregnant state. 

Chap. XIII. Atrophy. — This lesion depends upon the imperfect exercise 
of the nutritive function. " General atrophy, commonly called marasmus, 
emaciation, or consumption, frequently arises from organic disease of the 
lungs, heart, and stomachy and from morbid enlargement of the mesenteric 
ganglions." 

All animals have a period of growth, maturation, and decay. In senile 
atrophy the solids waste, and the fluids are changed in character. " The jelly 
which exists in such great abundance in young persons totally disappears in 
decrepitude, its place being usurped by albumen and fibrin." 

The causes of local atrophy may be cessation of the function of the organ, 
diminution of the nervous influence, deficient supply of blood, and inflamma- 
tory irritation. Under the last head our author says : "The irritation ex- 
cited by the presence of biliary concretions in the gall-bladder is sometimes 
followed by the complete wasting of that organ. Hepatitis often gives rise 
to atrophy of the parenchymatous structure of the liver; and orchitis, espe- 
cially when supervening on mumps, is not unfrequently succeeded by impo- 
tence. How the lesion is produced in these cases it is not easy to determine. 
It is probable that the chief fault is in the arterial capillaries, which cease to 
perform their accustomed functions, and thus allow the absorbents to carry off 
more than the usual amount of organic matter." 

Atrophy of the muscles, brain, uterus and mamma is well treated in each 
of the chapters of the special pathology devoted to these organs. 

We make no apology for recalling to the minds of our readers the following 
extract from the writings of one of the most gifted men at present adorning 
our literature. When speaking of general atrophy he says — 

"It could not be without interest to watch the changes of the body as life 
naturally ebbs — changes by which all is undone that the formative force in 
development achieved ; by which all that was gathered from the inorganic 
world, impressed with life and fashioned to organic form, is restored to the 
masses of dead matter; to trace how life gives back to death the elements on 
which it had subsisted ; the progress of that decay through which as by a com- 
mon path, the brutes pass to their annihilation, and man to immortality. With- 
out a knowledge of these things our science of life is very partial, very incom- 
plete ; and the study of them would not lack that peculiar interest which 
appertains to inquiries into final causes ; for all the changes of natural decay 
or degeneration in living beings indicate this design, that, being gradual ap- 
proximations to the inorganic state of matter, they lead to conditions in which 
the elements of the body, instead of being on a sudden and with violence dis- 
persed, may be collected into those lower combinations in which they may best 
rejoin the inorganic world; they are such that each creature may be said to die 
through that series of changes which may best fit it, after death, to discharge 
its share in the economy of the world, either by supplying nutriment to other 
organisms, or by taking its right part in the adjustment of the balance held 
between the organic and the inorganic masses. 

"Nor would the student of the design of these degenerations do well to omit 
all thought of their adaptation, in our own case, to the highest purposes of our 
existence. When, in the progress of "the calm decay" of age, the outward 



1858.] 



Gross, Elements of Pathological Anatomy. 



163 



senses, and all the faculties to which they minister, grow dim and faint, it may 
be on purpose that the spirit may be invigorate and undisturbed in the contem- 
plation of the brightening future; that, with daily renewed strength, it may 
free itself from the' encumbrance of all sensuous things, or may retain only 
those fragments of thought or intellectual knowledge which, though gathered 
upon earth, yet bear the marks of truth, and being truth, may mingle with the 
truth from heaven, and form part of those things in which spirits of infinite 
purity and knowledge may be exercised." 

Chapter XIY. treats of Fistules, and is very much out of place between 
Atrophy and Transformations. 

Chapter XY., Transformations. "The human body is incessantly under- 
going changes by which the nutrition of its elementary constituents is modified 
until they are at length converted into totally different structures." (!) 

The number of transformations is very small, and may be stated as follows : 
1, cellular; 2, mucous; 3 ; cutaneous; 4, fibrous; 5, cartilaginous; 6, osseous; 
7, adipose. Passing over the first four we come to the cartilaginous variety : 
it usually appears in the form of thin plates or nodules. The subserous cel- 
lular seems to be the texture the most liable to it. It occurs in the fibrous 
envelop of the spleen, in the placenta, the gall-bladder, cysts, adventitious 
membranes, &c. The new substance cuts precisely like a piece of costal car- 
tilage, and passes, by insensible gradations, into the circumjacent cellular tis- 
sue, which is generally unnaturally thick and indurated. It is in reality 
devoid of all the elements of cartilage. 

The most common transformation by far is the osseous. The new sub- 
stance, which often bears but a faint resemblance to natural bone, is seen 
under three forms, the lamellated, tuberoid, and spicular; but in the majority 
of cases this so called osseous transformation does not present the usual uni- 
form characters of true bone; it is rather a calcareous degeneration or a 
deposit of chalky particles, with an absence of the natural elements of bone. 
Accidental ossification is frequently witnessed in old age — the arteries, costal 
and laryngeal cartilages are thus affected. In other cases it is directly charge- 
able to inflammation. 

"But the most remarkable transformation is the adipose, in which the tis- 
sues undergo a real fatty degeneration. In the majority of cases it-is a true 
replacement of tissue by oil. By some the alteration is supposed to consist, 
essentially in the superaddition of fatty matter to the existing tissues, whilst 
others consider it as the result of a true transformation." But no one, it 
is fair to suppose, who has read Quain and Robin, confounds these two essen- 
tially different processes. 

How is it brought about? "In the human subject it sometimes seems to 
depend upon the want of exercise of the affected part. But are these effects 
really attributable to repose. Would it not be more philosophical to conclude 
that something was due to the want of nervous influence, and to the altered 
state of the circulation thence arising. Be this as it may, I feel disposed to 
think that the transformation in question is uniformly the result of a low and 
imperceptible grade of inflammatory irritation." This last sentence is not the 
only unsatisfactory part of this paragraph. 

Under the head of " Pneumatoses, or Collections of Aeriform Fluids," is 
included the general consideration of pneumo-thorax, tympanitis, physometra, 
pneumo-pericardium, pneumatocele, emphysema, &c. 

The causes are external injury, chemical decomposition, and true secretion. 

The next chapter introduces us to the general subject of Tumours, a word 
which does not occur in the index of Dr. Gross's work, and is really an ob- 



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jectionable term; but its use may conveniently serve a purpose. Our author 
does not approach the subject as do those who have what might be called ra- 
dical notions on the subject of new formation. He does not build up his 
classification on a foundation of the nature, nor yet on any other good basis. 
It is both faulty and eccentric. 

Chap. XVII. Polypes. — We object that this word cannot properly stand 
for a class, as it relates merely to a matter of form, and may embrace every 
variety of tissue, homologous and heterologous. Dr. G. confesses that it is 
not very appropriate. After considering briefly the situation, number, size, and 
form, the author speaks of their structure. "In this regard polypes may be 
divided into four species, vesicular, fibrous, vascular, and granular. As to 
situation, it may be said in general terms, that the first variety occurs most 
frequently in the nose; the second in the uterus; the third in the rectum, 
ear, and vagina; and the last in the larynx and urinary bladder. These may 
all undergo the various transformations, The fibrous is most liable to become 
carcinomatous." Is such a transformation possible under any circumstances ? 
We do not believe it, if it is intended to convey the idea that fibrous tissue 
ever becomes carcinomatous tissue. 

In regard to their origin polypes cannot be viewed, strictly speaking, in the 
light of new formations, but rather as the result of a species of hypertrophy 
of the mucous membrane. The development of the granular from mucous 
follicles is traced and compared to the formation of a cyst from the closure of 
a sebaceous follicle. All these varieties are covered by a mucous investment 
continuous with that of the canal, from which they have sprung. They 
possess arteries and veins. No nerves or absorbents have been detected in 
these excrescences, though they undoubtedly exist there. 

Hydatids. — Dr. Gross divides them into 5 genera; 1, the cysticercus; 2, 
the polycephalus; 3, the diceras; 4, the echinococcus; and 5, the acephalo- 
cysts; they all consist of a thin pellucid vesicle, varying in size, which is 
filled with a clear watery fluid, and surrounded by a dense fibrous capsule, 
upon which they depend for their nourishment and support. 

These are well described by words and figures. The origin of hydatids is 
involved in doubt. Recent researches tend to show that they are the ova of 
worms, probably of the taenia, which reach a certain stage of development, 
and then become encysted. The embryos of taenia have been seen perforating 
the intestinal walls, in order to reach the parenchymatous structures in which 
they were destined to become imbedded. Whilst the formative process is 
going on, the parasite takes care to isolate itself by means of a capsule. This 
capsule formed out of plastic lymph, is furnished with vessels, nerves, and ab- 
sorbents ; these are derived either from the surrounding textures, or are of 
spontaneous formation. 

How are hydatids nourished ? They are isolated by a capsule, which is 
lined by a thin, pulpy, fragile lamella, which Dr. Hodgkin supposed to be an 
excrementitious secretion from the hydatid, but which Dr. Gross believes may 
be an important structure designed to nourish the parasite. Some hydatids 
are short lived, and some last for years. They may die of inflammation 
terminating in suppurative gangrene. 

This chapter, although one of the most thorough and complete expositions 
of the actual state of science to be found in the book, contains no notice of 
Kobin's remarkable explorations among entozoa. 

Serous cysts are often confounded with hydatids, but may be readily distin- 
guished by the fact of their being all intimately connected with the parent 
sac, by the circumstance of vessels passing from one to the other, and by their 



1858.] 



Gross, Elements of Pathological Anatomy. 



165 



not containing any parasitic formations. — \_Vide passim, Robin and Paget, 
Simon, Johnson, and Budd.] 

Chapter XX. Heterologous Formations. — This chapter, divided into six 
sections, introduces' the subject of heterologous formations. This is by far the 
best part of the work we have as yet passed in review. Much of it is admira- 
ble in style, and it is well illustrated by wood-cuts, old and new. Most of 
the latter made from drawings by Dr. Da Costa, whose valuable assistance has 
received from Dr. Gross the credit to which it was believed to be entitled. 

There are, however, in the following sections, many opinions and statements 
which may fairly enough be questioned. But, in accordance with the plan 
already pursued to this point, we prefer that our author should announce his 
ideas and fortify them in his own way. 

By the term heterologous are understood certain morbid products of a solid 
or semi-concrete consistence which have no resemblance whatever, or, at most, 
only a very remote one, to the natural, normal, or pre-existing tissues of the 
body. The number of these products is, probably, not more than six, viz., tu- 
bercular, scirrhous, encephaloid, colloid, melanotic, and epithelial. All the 
heterologous formations have one common property, they are all malignant, and 
tubercle is unquestionably the most malignant of all. Their origin is, probably, 
of an inflammatory nature, attended with an altered condition of the blood and 
an aberration of the nutritious function. 

Was there ever greater need of an Ashburton to settle boundary lines? 

Section I. Tubercle. — In this section we find many well-arranged and 
useful facts. As in other parts of the work, the external qualities of the pro- 
ducts of disease, including those ascertained by the microscope, are presented 
with marked fidelity and minuteness. 

Tubercle is limited by Dr. Gross in its application to denote "a small solid 
tumour of an irregularly spherical figure, more or less opaque, of a pale-yel- 
lowish colour, seldom exceeding the volume of a pea, and composed of a pecu- 
liar substance, which, sooner or later, undergoes a process of decomposition." 
Passing over what is said concerning the situation, period of life, its occurrence 
in the inferior animals, chemical constitution, we stop at varieties of form. 
Here we learn that tubercular matter presents itself under four distinct varie- 
ties, the miliary, encysted, infiltrated, and lamellated, besides that which is 
known as gray granulations, which Dr. G. regards as a variety of the ordinary 
gray tubercle. 

In regard to the formation, it is said that all tubercular matter, whatever be 
its form, site, or extent, is, in the first instance, of a liquid nature, becoming 
solid by the absorption of the serosity which is poured out with it. It grows 
by the superaddition of one particle to another. The effusion is always effected 
under the influence of inflammatory irritation, preceded by a peculiar dys- 
crasia. The doctrine of the inflammatory origin is countenanced, if not actu- 
ally established, by the following circumstances, says our author : — 

1. By chemical analysis. 

2. Tubercular matter bears a very great resemblance to spoiled, degraded, 
or cacoplastic lymph, which is an acknowledged product of inflammation. 

3. The deposit is often excited by cold, especially when conjoined with mois- 
ture and by bad food ; by the former are produced internal congestions, by the 
latter an impoverished blood. 

4. In many cases the disease is attended or preceded by hyperemia or ac- 
tive congestion. 

5. Well characterized tubercles have been produced on the lower animals 
experimentally, by mechanical irritation. 



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6. There is no appreciable deposit or effusion in any of the shut sacs, cells, 
or cavities of the body, which is not, strictly speaking, the result of inflamma- 
tory action, though this may be too slight to attract attention or to be attended 
by the ordinary phenomena of that process. 

This crowns the climax and completes the circle at one jump. Thus life 
and growth are inflammatory actions, and we ourselves are only compound 
inflammatory globules of considerable size. 

Are tubercles ever organized? In answering this question, it is apparent 
that Dr. G. takes that to be tubercle which Kobin, Wedl, Lebert, and others 
have shown not to be tuberculous. The little masses once described as tu- 
bercles comprehend many morphological elements. Besides cells with distinct 
nuclei, and nuclei mixed with molecules, and granular corpuscles, and the 
protein bodies with flocculent edges, there may be various other heterologous 
or homologous formations, as cancer, &c. ; so that a tuberculous mass may 
be like any other mass of tissues — a cancerous tumour even — made up of 
various elements. In tubercle as in other structures, there may be various 
pathological changes going on — degeneration, suppuration, exudation. But 
we think it is not to be inferred from this that tuberculous matter is organi- 
zable. To say that it has an organized blastema for its base is a different 
thing, and more in accordance with the results obtained by the most minute 
investigations. 

We refer the reader for Dr. Gross's able presentation of the other side of 
this double-headed question to pp. 158, 159 of the Elements of Pathological 
Anatomy. This section manifests throughout a conscientious use of most of 
the well-established facts, and a praiseworthy fairness in confessing to uncer- 
tainties in matters of doubtful knowledge. 

The paragraphs devoted to microscopical characters are full and compact, 
but we have not space for further extracts, and pass on. 

Section II. 31elanosis. — This subject introduces the subject of colouring 
matters, whose history is yet to be written. For this material has been fur- 
nished by Yogel, Virchow, Robin, Verdeil, Bence Jones, and Addison. 
From our own observations we are led to coincide with those who believe that 
all the pigments are but slight modifications of the one colouring matter of 
the blood, more or less oxygenized, and having slightly different molecular 
arrangements, whence they reflect light differently. They all have many 
common characteristics, the most remarkable of which is invulnerability; 
they are hard subjects, and resist assaults. The mortality which is supposed 
to depend upon melanosis we should no more refer to the deposit of melanine 
in the tissues than we should refer the deaths from Addison's disease to the 
bronzing of the skin. 

But in turning to our author we find him describing melanotic tumours as 
tuberoid, lamellated, dot-like, infiltrated, ramiform, and liquid; and we add, 
as an appendix, that it may be found in any form into which blastema or 
stroma may be arranged. The subject is treated by Dr. Gross at considerable 
length, and the section appropriated to it is one of the most interesting in the 
book. 

Sections III., IV. and V. treat respectively'of scirrhus, encephaloidand colloid. 
The imperfect definition which stands at the beginning of Section III. is an 
index of the false point of view from which Dr. G. regards all the new 
formations. It is from the external and anatomical side that the subject 
is viewed. Thus it is said : " Scirrhus may be defined to be a hard, crisp, 
opaque substance, of a light grayish colour, with dull, yellowish, fibrous in- 



1858.] 



Gross, Elements of Pathological Anatomy. 



167 



tersections organized, liable to lancinating pain, occurring for the most part 
after the middle period of life, and passing sooner or later into ulceration." 

Scirrhus may occur as a solitary tumour, in disseminated masses, as an 
infiltration, or as a lamella. After the general consideration of these forms, 
follows a good description of the appearances on section. 

The characteristic cancer-juice, on which Lebert, Nelaton, and others in- 
sist so much as one of the first-sight, reliable signs, is dropped with two lines 
thus — " a creamy-looking fluid is occasionally incorporated with the hetero- 
clite mass, and constitutes the most decided evidence of its carcinomatous 
nature." The student who reads this fact for the first time in this book — 
and we suppose that it is for that class of readers the book is chiefly designed- — 
will be at a loss how to turn the information to any account as an aid to a 
differential diagnosis. 

Scirrhous tumours present considerable variations of structure, dependent 
upon the quantity of adventitious matter, its vascularity, its mode of aggrega- 
tion, and the pressure which is exerted upon surrounding parts; whence 
names indicative of peculiar appearance have been assigned — such as mam- 
mary, pancreatic, lardaceous, and reticular. 

Under the head of organization, a very minute and complete description of 
the microscopic appearances is given, which we have not space to transfer. 

As a summary of several remarks our author says : " It may be concluded 
first, that the deposit of scirrhus is preceded by inflammation; secondly, that 
it has a great predilection for the glandular viscera; thirdly, that it rarely 
occurs under the age of forty ; fourthly, that the matter of which it consists, 
when first deposited, strongly resembles that of tubercle; and lastly, that this 
matter is deposited always into the cellular tissue of our organs in such a man- 
ner as to transform their proper parenchymatous structure." 

The scirrhous matter is liable to softening ; this change may begin at any 
part of the mass. 

A scirrhous ulcer is exceedingly well described by Dr. Gross, p. 176. 

Finally, scirrhus, after having attained a certain age and bulk, is occasion- 
ally assailed by destructive inflammation, followed by sloughing of the whole 
of the heterologous matter. 

The section in which encephaloid is treated, bears marks of an intermittent 
development. Scattered throughout it, and in the midst of a style every 
way scientific and appropriate, occur occasionally paragraphs which, from the 
absence of the new terms, the phraseology indicative of the late discoveries, 
show an origin of a much earlier date than the context. Thus, " intimately 
allied to scirrhus, in its mode of origin, yet differing from it widely in many 
of its essential features, is encephaloid * * * * as the term indicates, this morbid 
growth bears a great resemblance to the cerebral tissue, not only in appearance 
but also in chemical composition. " That is what Dr. Gross calls a great resem- 
blance, and illustrates like a steel cut, what we mean by the outside way of 
looking at pathological anatomy. It is to be hoped that the students will not 
confound resembling with analogous; if they should, they would have to 
look long, before finding any structures that could fairly be called heterologous. 

We think the space in which the forms, as tuberoid and stratiform, are 
described, should have been given to something more important. The forms 
are accidental, but, presented as we find them in this section, might be sup- 
posed to be a good basis for classification. 

It may be assumed that encephaloid, when first found out, is always fluid. 
Its structure is not uniform, and its consistence is so various that it has given 
rise to various designations. The well known microscopic appearances are 



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clearly described. For them and what is said on the chemical constitution 
and etiology of this form of cancer, the reader is referred to pages 180-184. 

The ulcerated mass sometimes sloughs completely away, as if dissected out, 
but is soon followed by a reproduction of the disease. It might be added 
that such growths are not likely to be injured by explorations with a needle, 
in the hands of a scientific man, nor yet radically cured by applications of 
chloride of zinc and sanguinaria. 

Section V. Colloid. — Known also as gelatiniform cancer, alveolar cancer, 
and gum cancer. "By some," says Dr. G., "this heterologous formation is 
regarded merely as a modification of the carcinomatous products already 
described." The same might be said of tubercle, scirrhous and encephaloid. 
It might have been added that some observers do not regard colloid as carci- 
nomatous at all. We agree with our author, in thinking it possessed of 
sufficiently distinctive features to entitle it to separate consideration. 

The description given of the structure is excellent, but we can give only a 
general idea of it. 

Colloid is composed of two distinct elements, a containing and a contained 
part — a stroma of fibrous tissue, forming cells of different sizes and shapes, 
freely communicating with each other, whence a colloid tumour bears some 
resemblance to a sponge. The other substance is a straw-coloured jelly, un- 
organizable. 

How this disease originates, or what its causes are, we are entirely ignorant. 
Its progress is usually slow. It manifests no disposition to ulcerate, is never 
the seat of hemorrhage, or of much pain ; the general health usually holds 
out well, and the countenance rarely acquires that sallow, cadaverous hue ; so 
common in ordinary carcinoma. 

Section VI. Epithelial Cancer. — This subject has received special atten- 
tion from Dr. Da Costa, and plates representing a papilla and encysted cells 
are taken from drawings by this microscopist. The section embraces a 
general view of all that is known on the subject, although no special reference 
is made to Lebert or Bennett. 

This brings us to the close of the first part of Dr. Gross's work, that which 
treats of general pathological anatomy. Its faults or errors of doctrine we 
conceive to be those of its class. It is too much anatomical, and too little 
pathological. We believe that Dr. Gross is as much convinced as we are, 
that there cannot be an exposition of morbid anatomy of any value, without 
pathology, but he always puts the anatomy first, and that disposition has 
controlled his figures of speech and illustrations, but especially his classifica- 
tion, and has compelled him, or permitted him, to leave the greatest things 
unsaid, or but faintly indicated. The great facts of diathesis, dyscrasise, 
and all that contributes to make idiosyncrasy, are overshadowed by protu- 
berant tumours, from the size of a billiard ball to a dinner plate, and re- 
sembling everything that ever has been served up on a dinner plate. We 
have brought in, by three or four pages, one after the other, peas, Lima beans, 
currant jelly, boiled egg, moist cheese, arrowroot, custard, potato, turnip, 
orange, mustard, calf's liver, and an adult head. These are here enumerated 
only for the purpose of illustrating our meaning. They are given by the 
author, to describe qualities, which, we think, are not of much consequence, 
and may be present or absent, without changing the character of the produc- 
tion, being indifferently applicable to all sorts of growths, heterologous and 
homologous. But it must be acknowledged that it is his aim to give his 
pupils clear ideas of these external properties, such as first strike the eye, and 
are noted by the quick diagnostician and prompt clinical lecturer, rather than 



1858.] Gross, Elements of Pathological Anatomy. 169 



the essential qualities, which the medical philosopher should look for. "We 
have, therefore, no doubt that the students, whose privilege it is to listen to 
Dr. G., receive from him well-defined principles for the diagnosis of external 
disease, and the coarser specimens of internal disease. But there is much 
more than this that comes within the domain of pathological anatomy. 

In the second part, treating of the application of general principles to spe- 
cial organs, we find nothing challenging criticism except the repetition of the 
doctrines to which we have already called attention ; but we do find much that 
indicates a vast erudition, and patient, conscientious labour. Its collection of 
facts is so great that it must ever be an extremely convenient vacle mecum on 
the office table — with other books, we should add parenthetically, for it re- 
quires those that are complementary by its side. 

Having now fairly presented Dr. Gross's doctrines according to his own 
classification and in his own style and method, we beg our readers to look, for 
the sake of contrast, at the ideas which have been generally adopted by the 
members of what may be called the French biological school, and are given 
here as an answer to the inquiry how anatomy should be studied and taught. 

The idea of life, properly speaking, does not belong to the organs and tis- 
sues as such, but to certain elements which by their reunion make tissues. 
These elements may be considered (a) in relation to their form or size; (b) in 
relation to dynamic attributes. They have, 1, physico-chemical properties, and 
2, vital properties. 

There are, I. Constituent Elements: II. Elements of Production. 

I. Constituent elements are divisible into (a) amorphous elements, (j3) 
globules, cells, nuclei vesicles, (y) fibres, (S) tubes, canals, ( £ ) amorphous sub- 
stances mixed with corpuscles, cells and cavities. 

II. Elements of Production may be (a) Homceomorphic, (j3) Heteromor- 
phic productions, as globules of exudation, globules of inflammation, of pus, 
cancerous elements, corpuscles of tubercle. 

All compound tissues consist of, 1st, a fundamental form or species of ana- 
tomical element which makes up the mass of the tissue, and whose properties 
give the specific character to the tissue, and, 2d, of one or more species of 
elements which do not enter into the constitution of the tissue except as ac- 
cessory, and whose properties only modify the tissue in a secondary manner : 
ex. gr. striated fibres are the essential anatomical element of muscular tissue; 
the accessory elements are areolar or laminated fibres, fat vesicles between the 
fibres, capillaries and nervous tubes. This law is of great consequence and 
should especially be borne in mind in the study of morbid products: thus — 

Homoeomorphic tumours exhibit this peculiarity ; an accessory element 
which nominally exists in small quantity becomes enormously increased rela- 
tively and finally predominates over the fundamental tissue and really becomes 
the fundamental tissue. • Most of the amorphous substances, the homogeneous 
intercellular substances which in the normal condition are quite secondary or 
accessory, may become greatly multiplied, as is seen in epithelial, tubercular, 
and cancerous formations. 

The Heteromorphous tumours present many examples' of the normal ele- 
ments becoming accessory, the nature of the production being unchanged. 
Globules of pus are often accessory elements of cancerous and epithelial 
tumours. Pavement epithelium is also accessory and secondary in cancerous 
tumours. The granular globules of exudation are secondary elements of a 
large number of tumours. 

By Homoeomorphic elements are understood morbid fluids or tissues con- 



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stituted by anatomical elements of the same nature as those existing in nor- 
mal tissues and fluids. 

Heteromorphic elements are new productions, solid or fluid, differing in 
nature from those normally existing in the body; their presence is, therefore, 
a pathological sign. Examples: pus, granules of tubercle and cancer cells, 
and, according to Robin, one or two others not yet well known. 

These never have been observed to be the production of other existing nor- 
mal elements, by metamorphosis or as a consequence of simple development; 
they are always the results of processes of new 'production at the expense of a 
blastema found under abnormal conditions : thus, Products of new generation 
— neoplastic growths — are made up essentially of, 1st, an abnormal increase — 
hypergenesis — of elements which belong to the economy, but are normally 
secondary to some tissue : 2d, the production of elements which are essen- 
tially dissimilar from those which exist in the normal state. 

Blastema is a" generic word used to designate the basis of all anatomical 
elements, normal or morbid. Pathologically considered, there are as many 
different blastemata as there are causes of effusion. Whenever exudation of 
lymph occurs its nature depends upon the cause ; local or general, which ex- 
cited it. 

By the word tumour is meant a persistent collection of morbid productions, 
characterized by a tumefaction which is limited, but having no other fixed 
physical peculiarities. This definition embraces every variety of morbid tis- 
sue and concretion, as well as all collections of fluid circumscribed by new 
epigeneses, however these latter may have been produced, whether at the 
expense of the normal structure and fluids, or by means of heteromorphic ele- 
ments. 

The first observation to be made in relation to these growths or tumours is, 
that they are of a complex nature — of fundamental and accessory elements. 
These are relative elements, which are always shifting ground — sometimes an 
accessory element becoming, under other circumstances, fundamental. Amor- 
phous elements, however, remain accessory. These last are of great import- 
ance in relation to the differential characteristics of growths, for according as 
these amorphous elements exist in greater or less abundance, do we find the 
external appearances of the growth vary without essential change in the ele- 
mentary structure. 

Much embarrassment has been created in the course of earlier investigations 
with the microscope, from the fact that the new growths were not considered 
in their proper relation with normal elements, and especially from misconcep- 
tion as to the modifications to which the epithelia are subject, as regards their 
number, size, shape. 

The whole subject of morbid growths — deposits or exudation — in respect 
to their essential characters, their benignity or malignity, has been much sim- 
plified by the new methods of investigation, which now include, besides a 
measurement and description of each of the substances in the field of the 
microscope, and their quantitative chemical analyses, the study of the nutri- 
tion, growth, and reproduction. 

Still another advance has been made by the discovery that behind the par- 
ticular growth which is the subject of observation, there is an inexhaustible 
fountain of materials assimilable to it, and a constant vis a tergo which keeps 
the current towards it in active motion j "new fresh blood is constantly cir- 
culating." Practically, then, tumours cannot be made to absorb. This rule 
has but few exceptions. The same law which is an obstacle to their absorp- 
tion is the cause of their reproduction after their removal. That means for 



1858.] 



Gross, Elements of Pathological Anatomy. 



171 



effecting a change of the dyscrasia, for a constantly increasing number of 
morbid products are in hand ; is a matter of fact. In that direction the sci- 
ence of Therapeutics makes progress. 

" It is a law binding only on devils and phantoms that they must go out 
the same way they stole in." Once these sprouting tendrils get in, the death 
struggle begins — one or the other must be cut off — there is no remedy but 
ablation, and that to be early enough. 

On the basis of the preceding facts and dogmas a classification of morbid 
productions has been erected the most complete that can be found in medical 
literature ; but before we proceed to quote it let us look, by way of compari- 
son, at some others. One of the best in design, though at this time quite 
limited and incomplete, is Bichat's arrangement. He begins with alterations 
of the fluids; then follows a brief chapter on inflammation; then the mala- 
dies of serous membranes in general and particular; then maladies of the 
mucous membranes ; maladies of cellular tissue follow; and maladies of the 
lungs. Maladies of the glands in order: Maladies of the cutaneous surface; 
maladies of the muscles of organic life; maladies of the muscles of animal 
life; maladies of the absorbent system; maladies of the fibrous system; mala- 
dies of the synovial system; maladies of the cartilaginous system; maladies 
of the medullary system ; maladies of the osseous system; maladies of the 
pilous system; maladies of the epidermic system. 

The arrangement followed by Mr. Paget in his Lectures on Surgical Pa- 
thology is quite scientific, and one of the best and most convenient for use 
that can be found. We therefore make no apology for asking our readers to 
look it over again in this connection. This author very properly begins his 
discourses on Pathology with an exposition of the processes of nutrition and 
passes seriatim through growth, hypertrophy, atrophy, repair, inflammation, 
and ends this first part with local or molecular mortification, limited death. 

Having finished the consideration of Inflammation, the general malady or 
basic disease, according to some pathologists, Mr. Paget begins anew with 
specific diseases, and, passing to morbid materials in the blood and tissue, 
comes to the second chapter, on Overgrowths or Tumours. These are either 
benign or malignant. 

The benign are divisible into cystic and solid. The cystic, simple, barren; 
gaseous and serous cysts: proliferous, ovarian: proliferous, glandular, mam- 
mary; epidermal, dentigerous: fatty, fibro-cellular, areolar: fibrous, painful 
subcutaneous: fibrous polypi, fibro-calcareous; fibro-cystic: malignant fibrous, 
recurring fibrous ; fibro-nucleated : enchondroma, cartilaginous, simple and 
mixed: myeloid; fibro-plastic, osseous: mammary: erectile: — all these are 
innocent or benign. 

The malignant are : Scirrhus, medullary cancer, epithelial cancer, melanoid, 
hsematoid, osteoid, villous, colloid, tubercles. 

Dr. Gross's classification may be thus represented : Inflammation at the be- 
ginning, fons et origo; then its terminations and conditions, as effusion of se- 
rum, lymphization, suppuration, hemorrhage, softening, gangrene, ulceration, 
granulation, cicatrization, induration, hypertrophy, atrophy, fistules, trans- 
formations, pneumatoses, polypes, hydatids, serous cysts, heterologous forma- 
tions, tubercle, melanosis, scirrhus, encephaloid, colloid, epithelial, and then 
special pathological anatomy. This we believe, after thoughtful looking, could 
not be made worse. 

The completest of all we have yet seen, excepting that of Bouchut's These 
de Concours, is this which follows : — 



172 



Reviews. 



[Jan. 



ORDER I. — Solid Homceomorphic Tumours. 

First Species. Tumours formed by Laminated Areolar Tissue. 

1st variety. Proper fibrous tumours. 

2d " Colloid. 

3d " Fibro-cystic tumours. 

4th " Fibrous — Pediculated — Uterine. 

5th " Cheloides cicatricial. 
Second Species. Fibro-Plastic Growths. 
Third Species. Myeloplaxis — Osseous Medullary. 

Fourth Species. Tumours of Cytoblastions — Chalazion Gumma — Yams — 

Syphilitic Fungosities. 
Fifth Species. Myelocysts — Cerebral Cellules. 
Sixth Species. Dermic, 
f 1st variety. Keloides. 

2d " Keloid, or cicatricial vegetations. 
■{ 3d " Condylomita — Cauliflower excrescences. 

•^th " Nsevi — Hypertrophic. 
[ 5th " Verruca Warts. 
Seventh Species. Adipose Tumours — Cholesteatomata — Lipomata. 
Eighth Species. Enchondromata. 

1st variety. Periosteal tumours. "] 
j 2d " Exostosis. 
I Ninth Species. 

L 3d variety. Osteoid, periarticular, senile, and rheumatismal. J 
Tenth Species. Hypertrophic, Glandular, Exdermoptoses, and Sebaceous. 
Eleventh Species. Condensed Glandular Tumours. 
Twelfth Species. Colloid Glandular Tumours. 

1st variety. Arterial fungous tumours, acquired — Aneurism. 

2 " Nasvi materni — Congenital erectile tumours. 
Thirteenth Species. 

3d variety. Varicose venous erectile tumours — Epididymitic — Tes- 
ticular — Thyroidal — Ovarian. 

4th. " Aneurism by erosion — Extravasated blood — Dissecting 
and osseous aneurism — Erectile tumours of liver. 
Fourteenth Species. Parasitic — Heterotopic. 

1st variety. Testicular. 

2d " O.varian. 

3d " Cutaneous. 



r 



OQ fH P 

P m O 

£ M P 

a p 

° 3 H 

P « 



1st variety. 

2d 
3d 

4th " 

5th " 

6th " 

7th " 



Epitheleomata. 
Horny tumours. 
Pigmentary — Melanosis. 
Exostoses dental. 
Gouty concretions — Tophaceous. 
Calcareous tumours — Inter- glandular — Cutaneous- 
Salivary. 

Tumours formed by products of conception — Moles. 



p i m 

P £ P 

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ORDER II.— Homceomorphic Tumours — Fluid. 

First Species. True Aneurisms, 
i Second Species. Haematic Tumours — Cephalhsematoniata — Hematocele 

— Polypiform — Hsematomata. 
I Third Species. Gaseous Tumours — Emphysema — Pneumatoses. 



P o 



J jFVrstf Species. Glandular Cysts of many varieties. 

Second Species. Cysts formed in Excretory Ducts. 
J Third Species. Cysts formed of Parenchymata, not Glandular. 
] Fourth Species. Cysts, Synovial. 
Fifth Species. Cysts of Accidental Synovial Bursas. 
& Sixth Species. Cysts of Cellular Tissue — Congenital — Hydrocephalic. 
3 I / 



1858.] 



Peaslee, Human Histology. 



173 



f ORDER I. — Solid Heteromorphic Growths. 

First Species. Tubercle. 
Second Species., Typhus Matter. 
Third Species. Thnetoblastic, or Fatal Cancer. 
Fourth Species. Heterodenic — Butyroidal Sacs. 
^ Fifth Species. Tumours resulting from Anatomical Wounds. 

ORDER II. — Liquid Heteromorphic Tumours. 
First Species. Purulent — Abscess — Anthrax — Furuncle. 

Second Species. Parasitic Tumours — Cysticercus Hydatids with Echinococci — 
Hydatids without Echinococci. 

In our summary we call disease any disorder of the forces or of the consti- 
tuent parts of the body. But, absolutely, there is no health. There is always 
disease, with more or less of actual and prospective manifestation. There is 
always a disturbance from the too much or the too little, if not from empoi- 
sonment or other harmful absorption. There is no more likelihood of abso- 
lute health than of an absolute quietude of the winds, or an absolute electrical 
equilibrium. So long as there is variableness of temperature, so long will 
there be disturbances of the media, and so long disturbance of the functions 
of organisms. As long as the sun shines will continents upheave, and blaste- 
mata degenerate. When will the media be at rest? Not till then will the 
forces and the elements within the body of man be at rest. 

So long as the sun chimes in with the music of his brother spheres, and 
the pomp of the earth revolves, and the " brightness of paradise alternates 
with deep-fearful night" — and the "sea foams up in broad waves," and 
storms roar — so long shall the body of man be sick, and his mind unstable ; 
so long shall there be sins for repentance and sorrow for consolings. As long 
as aggregate cytoblasts shall be prone to disturbances, so long shall masses of 
men be liable to revolutions and conflicts. So long as there shall be social 
sins and degradations, so long shall there be maladies of individual or- 
ganisms. 

Thus " all revolves into the whole, and through the All, ring harmoniously 
all the heavenly influences." C F. H. 



HP 



HH I— I 

J O 



Art. XV. — Human Histology, in its Relations to Descriptive Anatomy, 
Physiology, and Pathology. With 434 Illustrations on Wood. By E. 
K. Peaslee, A. M., M. J)., Prof, of Physiology and Pathology in the 
New York Medical College, of Anatomy in Dartmouth College, and of 
Surgery in the Medical School of Maine, &c. &c. Philadelphia : Blanch- 
ard & Lea, 1857. 8vo. pp. 618. 

The plan of Prof. Peaslee' s book is to combine in a single volume a de- 
scription of the ultimate chemical elements entering into the composition 
of the human body, that of the proximate principles, of the anatomical or 
structural elements, and of the tissues proper, together with some account 
of their healthy functions, and the morbid alterations to which they are 
subject in disease. The first part is accordingly devoted to the consideration 
of the chemical elements and the proximate principles ; and the second part 
to the more purely anatomical description of the minute forms and structures 
demonstrable by the microscope. 

No. LXIX.— Jan. 1858. 12 



17-1 



Reviews. 



[Jan. 



The consideration of the ultimate chemical elements of the animal frame, 
naturally requires but a very limited space. It amounts, properly, to little, 
more than an introduction to the main subjects of the work. For a know- 
ledge of the ultimate elements into which the animal solids and fluids can 
be decomposed by chemical operations, though essential as a basis to the 
commencement of anatomical and physiological studies, really carries us on- 
ward but a very short distance in their prosecution. The cases are quite rare, 
in the present state of our scientific attainments, in which any important 
anatomical or physiological question can be decided by investigations in that 
direction. 

We may indeed determine, as Boussingault has done, by comparing the 
total quantity of nitrogen taken in with the food with that discharged in the 
excretions, whether this substance be habitually absorbed or eliminated in 
the process of respiration; and in some instances the presence or absence of 
the same element becomes an important distinctive characteristic of various 
animal substances. But the business of the anatomist and physiologist is, 
after all, mostly with the proximate principles, and not with the ultimate 
elements of which they are composed. The characters of the former are, 
to a great extent, peculiar, and their transformations in the living body 
readily subject to observation. The latter are not at all distinctive of or- 
ganized bodies, and the changes which they undergo in the animal economy 
are, for the most part, too obscure to be followed by the contrivances of the 
experimenter. 

In describing the proximate principles, the author has adopted the plan of 
Robin and Yerdeil, first brought forward in their admirable work on Physio- 
logical and Anatomical Chemistry, published at Paris in 1853, and which was 
reviewed in our number for July last {see p. 158, et seg.) It is very grati- 
fying to see that the views advanced in this work, so full of originality, and 
at the same time so extremely useful in their application, have met with a 
generally prompt and cordial reception on this side the Atlantic. The true 
nature and relations of the proximate principles, and the manner in which 
they should be studied, were indeed never fairly understood before the ap- 
pearance of Robin and Verdeil's book. They treated the subject from an 
entirely novel point of view, but one which seems only to have required a 
fair and distinct announcement to be almost universally acknowledged as 
correct. A proximate principle, according to this view of the matter, is a 
substance which may be extracted from an animal solid or fluid by means 
which do not destroy or alter its chemical nature and properties. Proximate 
principles may, in fact, be said to exist in all homogeneous solids and fluids 
of mixed composition, and may be extracted from them by the same means 
as in the case of the animal tissues and secretions. Thus, in a watery solu- 
tion of sugar, we have two proximate principles; 1st, the water, and 2d, 
the sugar. The water may be separated by evaporation and condensation, 
after which the sugar remains behind in a crystalline form. These two 
substances have therefore been simply separated from each other. They 
have not been decomposed, nor their chemical properties altered. On the 
other hand, the oxygen and hydrogen of the water were not proximate prin- 
ciples of the original solution ; for they did not exist in it under their own 
forms, but only in a state of combination, and in the form of water — a fluid 
whose physical and chemical properties are entirely different from theirs. If 
we wish to ascertain, accordingly, the nature and properties of a saccharine 
solution, it will afford us but little satisfaction to subject such a solution to 
an elementary analysis ; for its nature and properties depend not so much 



1858.] 



Peaslee, Human Histology. 



175 



on the presence of the ultimate elements — oxygen, hydrogen, and carbon — 
as on the particular forms of combination (water and sugar) under which 
they exist. 

These considerations, which are so plain in regard to a simple fluid like a 
watery solution of sugar, become still more important when applied to mix- 
tures of a complicated character, such as the- animal tissues and fluids. In 
examining these substances, their ingredients must be, as above, simply 
separated from each other, not decomposed. The analysis of an animal solid 
or fluid is therefore properly an anatomical operation, and not a chemical 
one, and must be conducted from an anatomical point of view, so as to pro- 
duce results useful to the anatomist and physiologist. So fully was Robin 
impressed with this idea, that he at first wished to adopt for his book the 
title, Fundamental Anatomy and Physiology, instead of Anatomical and 
Physiological Chemistry. Though the former would have been altogether the 
more correct title, in a scientific point of view, he adopted the second, " in 
order/' as he expressed it, " not to break away too suddenly from the esta- 
blished association of ideas, and thereby run the risk of not being fully 
understood." 

Since the investigation of the proximate principles, therefore, is really to 
be regarded as an anatomical and not as a chemical pursuit, it very properly 
precedes the study of microscopic anatomy, which is to carry us one step 
farther in the examination of the complicated structure of the animal frame. 
Robin's Chimie Anatomique was, in fact, designed by him as the introduc- 
tion to a work on Minute or General Anatomy, which has yet to make its 
appearance. 

Dr. Peaslee has united the two subjects, as we have mentioned above, in 
a single volume, but has retained the order of precedence, treating first of 
the proximate principles, and afterward of the minute anatomical forms of 
which the tissues are composed. 

The water, for example, which enters, as a proximate principle, into the 
composition of different parts of the animal frame, is to be extracted and 
examined as in the case of the simple saccharine solution above mentioned. 
All the animal solids and fluids, without exception, are thus found to contain 
a certain proportion of water, which may be separated by the process of eva- 
poration. The water, furthermore, which is obtained in this way, from the 
solids as well as from the fluids, is not simply entangled in the interstices of 
the former, but actually united everywhere with their substance. The pecu- 
liarity of the condition, therefore, under which the water exists in the tis- 
sues, becomes evident; for in those which are firmest in consistency, such as 
the bones and teeth, the water which they contain is actually in a solid form, 
not crystallized, as in the case of ice, or of saline substance which contain 
water of crystallization, but amorphous and solid, simply by the fact of its 
intimate union with the animal and saline ingredients of the tissue. The 
water is therefore, in these cases, solidified by the matter with which it is in 
union, as, under other conditions, solid substances may themselves become 
fluid when* dissolved in water. 

Different proximate principles being always mingled together, in this way, 
in the animal fluids, form their simplest or fundamental anatomical consti- 
tuents, and hence the propriety of the title, Fundamental Anatomy, pro- 
posed by Robin for the study of this subject. Every tissue, furthermore, 
and even every anatomical form, no matter how minute, consists of a mix- 
ture of at least two, and generally many more, proximate principles inti- 
mately united with each other. Every muscular fibre, and even each fila- 



176 



Reviews, 



[Jan. 



ment of white fibrous tissue, not more than 2 oio o tn °f an ^ ncn m thickness, 
if isolated and examined, would be found to contain, on the one hand, water, 
and, on the other, a peculiar animal matter in union with it. Several sa- 
line substances are also always present, in varying quantity. Each red glo- 
bule of the blood, not more than g^^th of an inch in diameter, yields to a 
properly conducted anatomical analysis : 1st, water ; 2d, two different animal 
substances (globuline and hsematine) ; 3d, fats, in a free or saponified con- 
dition ; and 4th, no less than eight different saline substances. It will readily 
be seen, therefore, that in a strictly scientific arrangement, the study of the 
proximate principles holds the first place, and that of the fluids, the micro- 
scopic elements, and the tissues, the second and the third. Practically, of 
course, it is different. Before analyzing any particular portion of the frame, 
we must become familiar with its figure and dimensions, so as to isolate it 
from the surrounding parts ; but once having done so, the subsequent arrange- 
ment of our anatomical studies must be in the order which we have indicated 
above. 

In the first division of the part devoted to microscopic anatomy proper, the 
author treats first of the simple histological elements, and afterward of the 
tissues. The simple histological elements are divided into — 

1st. Homogeneous substance. 
2d. Simple membrane. 
3d. Simple fibre. 
4th. Cells. 

The first of these, or homogeneous substance, is an important anatomical 
element, owing to its wide distribution, and the large quantity of it which 
exists in the body. There is hardly a tissue or an organ which does not 
contain more or less of it. It is this which occupies the space between the 
cells of cartilage and between the filaments forming the bundles of areolar 
tissue. It unites the scattered cells and fibres which are imbedded in it into 
a continuous and more or less resisting mass. It is a substance which can- 
not be directly observed under the microscope, owing to its amorphous con- 
dition, and the uniformity of its appearance. Its presence is only indicated 
by observing that the cells and granules, or the fibres and fat globules seen 
under the instruments, are not floating loosely about the field, but are re- 
tained in their position by the intervening material. It is only in some in- 
stances where it is more or less granular in texture, as in the case of some 
kinds of cartilage, that it can be directly seen. Here, however, the above 
name ceases to be entirely applicable, as it is no longer a strictly homogene- 
ous substance. 

Notwithstanding the importance of this material, as an anatomical ingre- 
dient of the tissues, but very little can be said of it since it exhibits no 
definite characteristics under the microscope ; its optical properties being, 
in fact, altogether negative in character. Very widely different substances, 
so far as regards their proximate constitution and their physiological proper- 
ties, will present precisely the same appearance under the microscope, pro- 
vided they be completely homogeneous. Even the plasma of the blood, when 
examined by the microscope, differs from the hyaline substance of cartilage 
only by its fluidity. The term homogeneous substance, therefore, is a gene- 
ral, not a specific term. It does not belong to any particular anatomical 
element, but only indicates a certain combination of optical properties which 
may be shared by several indifferently. 

Simple membrane is a special form under which the above-named homo- 



1858.] 



Peaslee, Human Histology. 



177 



geneous substance shows itself. It occurs, according to the author, in the 
walls of cells, in the sarcolemma of muscle, and the tubular covering of 
nerve fibres. In it are often imbedded nuclei, as, for example, in the case 
of the capillary bloodvessels, &c. Very nearly the same remarks may be 
made as to the varying characters of this membrane in different tissues and 
organs, as we have already given above in regard to the homogeneous sub- 
stance. It is, in fact, not identical in the different situations in which we 
meet with it, but is really to be regarded as often composed of different sub- 
stances, presenting themselves under the same apparent form. 

Simple fibre is also spoken of as one of the elementary forms of the ani- 
mal tissues. The term " simple fibre" would be generally understood to 
include all fibres of homogeneous structure, such as those of white fibrous 
tissue, or of elastic tissue, as distinguished from the compound fibres of 
nerve, or of voluntary muscle. The author, however, restricts this term to 
the interlacing fibres of the membrane of the egg-shell, and those of coagu- 
lated fibrin, when it exhibits the peculiar condition known as " fibrillation." 
Understood in this sense, the simple fibre is hardly to be regarded as an or- 
ganized anatomical element, since it is simply the effect of coagulation tak- 
ing place in the fluid fibrin, and does not form an integral part of any of 
the permanent tissues. The fibrillation of fibrin, indeed, is regarded by 
many, and, we think, justly, as not, in any degree, a form or process of or- 
ganization, but one merely of solidification — the coagulated fibrin being inert 
and useless for all purposes of nutrition or textural development; as much so 
as coagulated albumen or coagulated casein would be, under similar circum- 
stances. Whenever new formations of a permanent character, therefore, 
show themselves subsequently to the deposit of a fibrinous exudation (such 
as vascular and fibrous pleuritic or peritoneal adhesions), it is not the coagu- 
lated fibrin which is supposed to be directly converted into these new tissues. 
The fibrin is thought to be reabsorbed after its exudation, as extravasated 
blood or serum would be, and as happens also, in some instances, with pus ; 
while the new tissues are produced by a slow process of nutrition and growth, 
the materials for which are exuded gradually in a liquid form by the neigh- 
bouring parts, as the process of formation goes on. This is the view enter- 
tained by Robin, and one which has many points of evidence in its favour. 

In the chapter on Cells, the author passes in review the anatomical cha- 
racter of the nucleus, nucleolus, and other parts of the cell structure. He 
regards the ovum, also, as a cell; with the germinative vesicle as a nucleus, 
and the germinative spot as a nucleolus. The adipose vesicle is, besides, in- 
cluded in the same category. Both these forms are considered by some 
microscopists as distinct from true animal cells, not only by their very much 
larger size, but also by the details of their anatomical organization. The 
peculiarities of pigment cells, in different parts of the body, are described 
in the same chapter, and finally those of cancer cells, cancer nuclei, &c. In 
regard to the latter the author adopts the views of Lebert, which have been 
received with such general favour by microscopists in this^ country as well as 
in France. 

In the second division we have " Hydrology/' or the description of the 
fluids of the human body, as follows : 1st, the blood ; 2d, serous secretions 
and exudations ; 3d, mucous and glandular secretions ; and 4th, the cuta- 
neous secretions. In treating of mucus the author describes certain micro- 
scopic elements, the " mucous corpuscles," which he regards as a regular 
product of development from the albuminoid ingredients of the fluid. These 
corpuscles, which present very different appearances in different kinds of 



178 



Reviews. 



[Jan. 



mucus, are considered by some authors as characteristic of mucus, in the 
same manner as pus-globules are characteristic of pus. Many directions 
have accordingly been given, from time to time, for the purpose of enabling 
the observer to distinguish microscopically mucus from pus ; but the charac- 
ters relied on for this purpose were so indefinite that they have been found 
of but little practical utility. Many of the bodies described as mucus- 
corpuscles are undoubtedly pus-globules, accidentally present in the secre- 
tion; for nearly all mucous membranes produce pus, in greater or les abund- 
ance, on very slight irritation. Others are, as plainly, abnormal or imperfect 
epithelium cells, separated accidentally from the free surface of the mem- 
brane, and mingled with its fluid secretion. These facts have led some 
microscopists, of very high authority, to express the opinion that there is no 
such thing as a " mucous corpuscle," properly speaking; that is, that there 
is no constant and peculiar microscopic element characteristic of mucus, as 
the pus-globule and the blood-globule are of their respective fluids. Mucus, 
as they understand the term, is simply a mixture of watery, saline, and 
albuminoid ingredients, presenting no anatomical form to the eye on micro- 
scopic examination, any more than the serum of the blood, the synovial 
fluid or the pancreatic juice : but having a perfectly colourless and transpa- 
rent appearance, and a more or less viscid consistency. "We confess that 
this view seems to us altogether the most correct one ; since when mucus is 
collected from situations where no foreign admixture has been possible, as 
where it has been taken, for example, directly from the cavity of the follicles 
of the cervix uteri, it is actually perfectly clear and transparent to the naked 
eye, and does not show any anatomical forms on microscopic examination. 
Mucous secretions become opaline and discoloured, just in proportion as they 
are mingled with other fluids of a different consistency, or with puriform 
and epithelial elements. Practically, however, we seldom observe them in 
a condition of complete purity, unless we take the trouble, as above men- 
tioned, to obtain them directly from the situations in which they are pro- 
duced. 

Beside the microscopic elements of the animal fluids, the author speaks 
of their physical properties and their chemical constitution. A very 
important fact concerning these fluids, and one which could not have been 
anticipated beforehand, is the remarkable quantity in which some of them 
are secreted. The experiments of Bidder and Schmidt on the gastric juice 
in dogs, for example, led to the conclusion that the quantity of this fluid 
secreted in twenty-four hours was not less than y^th the weight of the whole 
body ; and though the same estimate applied to the human subject would 
give 12 to 18 pounds of gastric juice per day, these numbers are probably 
rather below than above the real quantity ; for all the fluids are, generally 
speaking, more abundant in the human subject than in the lower animals. 
The difficulty which is generally felt in accepting so high an estimate of the 
daily quantity of these secretions as the true one, is, however, rather appa- 
rent than real; and it is possible that even a much larger quantity may be 
discharged daily by the glandular apparatus of the mucous membranes, 
without producing any ill effect on the system at large. 

The author, for example, rejects some of these high estimates for a reason 
which we cannot but regard as altogether erroneous. 

"Experiments," he says (p. 199), "lead to the conclusion that dogs secrete 
in twenty-four hours an amount of gastric fluid equal to one-tenth their weight. 
This would give a range between 12 and 18 pounds for a man. Lehmann 
states, however, that ■ according to several direct observations on a woman, as 



1858.] 



Peaslee, Human Histology. 



179 



much as one-fourth of the weight of the body has been found to be secreted as 
gastric fluid ; ! ! ! Of course this is all secreted directly from the blood, and 
the latter is estimated by Lehmann to constitute but one-eighth of the weight 
of the body. ]S T o further remark appears necessary upon his estimate of the 
gastric fluid." 

It is in reality, however, not at all impossible that a quantity of gastric 
juice equal to 25 per cent, of the entire weight of the body should be secreted 
from the blood, which equals only 12$ per cent, of" the same weight. For 
the gastric juice is not separated at once from the circulating fluid, and dis- 
charged from the body. It is secreted gradually ; and almost immediately 
afterward begins to be reabsorbed, together with the elements of the food 
which it has digested and dissolved. Its secretion and reabsorption after- 
wards go on simultaneously; and the fluids which the blood loses by one 
process are immediately restored to it by the other. Examinations of the 
alimentary canal, while digestion is going on, show that there is comparatively 
but little fluid present in its cavity at any particular moment during this 
process; but, at the same time, the successive portions of gastric juice which 
enter the alimentary canal by exhalation, and then leave it by reabsorption, 
would amount, if taken together, to a quantity equal or superior to the entire 
mass of the blood. It is unnecessary to say, moreover, that in the experi- 
ments referred to by Lehmann, the entire quantity of gastric juice (7 pounds 
in the dog, 31 pounds in the human subject) was never actually withdrawn 
from the gastric fistula during any one day; but small quantities were taken 
at different intervals, and even in some instances on different days, at various 
periods after feeding; and the whole quantity estimated from these data. 
This estimate, furthermore, is fully borne out by the result of calculations as 
to the amount of food which a given quantity of gastric juice is capable of 
digesting. 

The third division comprises the description of the tissues. The classifica- 
tion of the tissues which is adopted is into simple and compound ; the simple 
comprising epithelium, yellow, and white fibrous tissues, and osseous tissue, 
including that of the teeth; the compound comprising areolar and adipose 
tissues, cartilages, muscle, nerve, membranes, vessels, alimentary canal, and 
the various glandular, respiratory, and sexual apparatuses, together with the 
organs of which they are composed. The simple tissues are defined to be 
those in which there is but one kind of simple histological element, while 
in the compound tissues there are two, three, or more of these elements 
mingled together. It will be seen that the author ranges osseous tissue, 
which would usually be regarded as compound, under . the head of the simple 
tissues; considering it as constituted, not by lacunae and canaliculi, and the 
soft substances which fill them, imbedded in a solid matrix — but by the solid 
matrix alone, this consisting, in its turn, only of the ultimate granules or 
minute angular corpuscles, welded together into laminge, which have been 
described by Bowman and others. 

^Ve doubt, however, whether this granular aspect of the bony substance 
should not be regarded in the same light as that of" cartilage, or as the 
granular texture of the substance of lymph and pus-globules, or of organic 
muscular fibres. The ultimate granules themselves, as they exist in the 
bony substance, are exceedingly minute. Their size is given (page 321) on 
the authority of Kolliker, as of an inch. This is undoubtedly a mis- 
print for solo oj which is really Kolliker' s measurement (.0002 of a line). 
Todd and Bowman give the size of these granules as <joVo *° ttsoo of an 
inch, and Tomes about tfooo to johov of an inch. The larger of these 



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measurements, however, are derived from the examination of bone which 
has been burnt and crushed, or boiled in a Papin's digester j while those of 
Kolliker are taken from the direct examination of the osseous substance in 
its natural condition, and are, on that account, probably the most accurate. 

In his description of the minute anatomy of the liver, the author has 
introduced the recent and extremely important discoveries by Dr. Beale, 
viz., the arrangement of the network of cell-containing tubes within the 
substance of the acinus, and their connection with the interlobular hepatic 
ducts ; as well as the dilatations or glandular sacculi, seated in the coats of 
the biliary ducts in some of the lower animals. 

The whole volume is plentifully illustrated with wood-cuts from the stand- 
ard works of Lehmann, Bennett, Todd and Bowman, and the classical 
Microscopic Anatomy of Kolliker, and, altogether, gives a very full and 
complete account of the histology of the human body, so far as it is known 
at the present time. J. G. D. 



Art. XVI. — The Principles and Practice of Obstetrics: Including the Treat- 
ment of Chronic Inflammation of the Uterus, considered as a Frequent 
Cause of Abortion. By Henry Miller, M. D., Professor of Obstetric 
Medicine in the Medical Department of the University of Louisville. With 
Illustrations on Wood. 8vo. pp. 620. Philadelphia: Blanchard & Lea, 
1858. 

On the appearance of the original edition of Dr. Miller's obstetrical 
treatise, we were among the first to introduce it to public notice, and the 
highly favourable judgment of its merits then pronounced by us, has been fully 
sustained by the suffrages of the profession generally. In the new edition 
now before us, the entire work has been greatly enlarged and improved, so as 
to give it a form and a value that cannot fail to place it permanently among 
our standard systematic treatises on the theory and practice of obstetrics. 

Without, perhaps, precisely the same elaborateness of detail and display 
of erudition which distinguish some of these, the work of Dr. Miller, by the 
clearness and distinctness with which each question embraced in it is dis- 
cussed and elucidated, and the direct practical tendency of all its teachings, 
is one especially adapted as well for the use of the student as for consultation 
by the practitioner, on the spur of the moment, that he may confirm the cor- 
rectness of his own conclusions, or detect their fallacy, by comparing them 
with those that have been arrived at from the experience and investigations 
of acknowledged experts. 

The treatise commences with an account of the physical structure of the 
pelvis — its forms, regions, diameters, planes, and axes — and of the anatomy 
of the sexual organs of the female, and their physiological functions. To all 
these subjects due prominence is given, as constituting some of the most im- 
portant points of that preliminary knowledge, an intimate acquaintance with 
which is essential to form the successful and safe obstetrician ; and without a 
perfect familiarity with which no one should be permitted to undertake the 
management of a case of labour. 

Dr. Miller adopts the modern view as to the menstrual discharge — that it 
is simply blood discharged by the vessels of the lining membrane of the 



1858.] 



Miller, Principles and Practice of Obstetrics. 



181 



uterus, but rendered uncoagulable by becoming mixed with the acid mucus 
and epithelial cells of the vagina. This view is so fully established by the 
investigations of Donne, "Whitehead, and others, that we are surprised the old 
notion of the menses being a specific secretion should be insisted on by so in- 
telligent a writer as Churchill in the latest edition of his Midwifery. 

The description of the pelvis, and of the female organs of generation, with 
their functions, is followed by a consideration of the clinical exploration of the 
uterus and its annexes; not merely with a view to the settlement of the ques- 
tion of the existence or non-existence of pregnancy, but also to determine 
whether any deviation or other abnormal condition of the womb or its annexes 
is present; extending thus the subject of the physical exploration of the 
female generative organs beyond the province of obstetrics, strictly speaking, 
into that of uterine pathology generally. How far this may be considered 
advisable in a treatise professedly devoted to the science and practice of mid- 
wifery may admit of question. As the author, however, has considered it 
necessary in a subsequent chapter, to enter at length into a consideration of 
the pathology and treatment of inflammation and displacement of the uterus, 
it was perhaps necessary that he should lay down, in the chapter before us, 
the physical means adapted to their detection and diagnosis. 

The subject of pregnancy is next discussed. In the several sections of the 
chapter devoted to this important department of female physiology, the reader 
will meet with a clear, succinct account of the successive changes that occur 
in the uterus itself, and in the ovum deposited in its cavity, from the period 
of conception up to the full term of utero-gestation. The several questions 
involved in the discussion of the important phases of uterine life are examined 
with much ability by the author, and his conclusions in respect to each will 
be found to be, in general, borne out by the results of recent observations. 

Speaking of the gradual development of the uterine cavity as the ovum aug- 
ments in size, and of the supposed antagonism existing between the muscles 
of the body and those of the neck of the uterus, in consequence of which the 
former, it is taught, tend constantly to expel the ovum, and the latter to resist 
its expulsion, until the close of the term of pregnancy, when the power of 
the body of the uterus preponderates, and the process of parturition com- 
mences and progresses, and the child with the secundines is expelled; speak- 
ing of this theory of the forced development of the uterine cavity until finally 
the cervix uteri is made to take part in it, which is taught by many distin- 
guished obstetrical authorities, Dr. Miller remarks : — 

"It is manifest that the theory rests on the assumption that the uterus is 
naturally disposed to resist, unguibus et rostro, all intrusions upon its premises, 
an assumption so contrary to analogy that it ought not to be admitted without 
the clearest proof. But let us examine its pretensions in its twofold applica- 
tion, and first as affording an explanation of uterine development. Here it 
seeks to expound a phenomenon which is itself gratuitously assumed, namely, 
such a development of the cervix as enlarges the capacity of the cavity of the 
gravid uterus. 

"According to the observations of M. Cazeaux, the neck, especially in women 
who have borne children, preserves the whole of its length until the last fifteen 
days of pregnancy, or at least until the commencement of the ninth month. 
He avers that he has repeatedly verified this fact, which had already been noted 
by Professor Stolz, of Strasburg, and publicly taught by Professor Dubois 
since 1839." 

"In primiparae, the cervix uteri offers some peculiarities, which, as far as 
our present subject is concerned, consist in its shortening somewhat, instead 
of preserving its usual length, throughout the greater part of pregnancy, as in 



182 



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[Jan. 



multiparge, and in its internal orifice becoming dilated before the external. 
Professor Stolz explains this shortening in the following manner : At the sixth 
month, the vaginal portion of the neck begins to shorten, while it widens at its 
superior part. The external orifice, continuing closed, approaches the internal, 
and consequently the cavity of the neck becomes larger in the middle, until the 
two orifices are brought near each other: the internal orifice then opens first, which 
happens during the last fifteen days of pregnancy ; the rest of the body disap- 
pears much more rapidly than it had done before, and a projection can no 
longer be felt; the external orifice remains closed." 

" The observations of Professor Stolz are substantially confirmed by M. 
Chailly; and the entire account, which he gives of the changes that the neck 
undergoes during pregnancy, contradicts the hitherto received opinions of 
writers on the subject. 

" There is one well-known fact, to which we may allude, that goes far to 
establish the accuracy of these reseaches of MM. Stolz, Dubois, Cazeaux, and 
Chailly, if it be not of itself sufficient to refute the opinion formerly entertained. 
It is this: When the neck of the uterus is so much developed as to allow the 
finger to be passed to its upper orifice, which it is by the seventh month in 
multiparae, the membranes can be felt, and are organically united to the uterus 
around the margin of the orifice. When, again, the neck is entirely obliterated, 
as it is at term, the membranes can be felt, and are still attached around the 
os uteri. Now, as it is admitted that during the first five or six months, the 
ovum is confined to the cavity of the body, and that the neck is not lined with 
decidua, were the obliteration of the neck owing to the expansion of its upper 
part, either the membranes would be too high to be reached by the finger; or, 
if they were sufficiently extensible to be pushed down into the expanding neck 
by the growing ovum, they would not be found adhering to its surface. The 
latter declaration is authorized by the fact that, in the progress of gestation, 
the membranes become less vascular, and their adhesion to the internal surface 
of the uterus is gradually weakened. But in either case, at the seventh or 
ninth month, the membranes are found to have vascular connection around 
the uterine orifice, for when separated by the finger, or by uterine contractions, 
as in the latter case they are, so soon as labour commences, there is a slight 
effusion of blood. We conclude, therefore, that the neck contributes nothing 
to the cavity of the gravid uterus, which is made up entirely of the dilated 
cavity of the body." * * * 

" The secondary application of the theory to explain the induction of labour 
is best met by demanding the proof that the uterus displays, during gestation, 
such intolerance of its burden as is attributed to it." 

" There is absolutely no evidence of such contractile efforts of the uterus as 
this theory assumes, except the occasional tension of the membranes, some- 
times observed towards the completion of gestation, the os uteri being then 
sufficiently open to admit the finger. Slight contractions of the fundus may 
produce this tension, but these are not such as constitute labour, for they are 
unaccompanied by pain, and take place without the consciousness of the indi- 
vidual herself. Allowing, however, that they are labour-pains in disguise, 
their presence at so advanced a period of pregnancy is no proof of their exist- 
ence during the earlier periods ; and in the complete absence of such proof, we 
are loath to admit the assumption that they do exist, because it makes the uterus 
the strangest anomaly in the body, if not in nature. It is destined first to contain 
and nourish the foetus, and then to expel it when its maturity is acquired. But, 
according to this assumption, the first is an irksome task imposed upon it which 
it continually endeavours to quit by expelling its contents. Such a constitu- 
tion of the gestative organ could hardly exist, and abortion be not perpetually 
threatened, without, as far as we can perceive, any compensating benefit ; for 
we cannot imagine that its development could be promoted by it. There is, in 
fact, no conceivable way in which contraction of the uterine fibres during preg- 
nancy could favour their development, except that imagined by Baudelocque, 
viz., one class of fibres stretching another by the superior force of their contrac- 
tions by which he attempts to account for the development of the cervix uteri. 
How, then, are the fibres of the body of the uterus developed during the first 



1858.] 



Miller, Principles and Practice of Obstetrics. 



183 



six or seven months of gestation, the neck being quiescent all the while? If 
these need no such force to aid their development, neither do those of the neck ; 
both are developed after their own peculiar fashion, without the interference of 
one with the other.' The neck, as we have seen, is developed in women who 
have borne children, in a manner inconsistent with the idea that any sort of 
force is exerted upon it by the body, that is, from below upwards." 

"From what has now been declared, it may be inferred that I reject the notion 
of Levret, indorsed by Baudelocque, and more recently by Meigs, that the neck 
is the antagonist of the body of the uterus, during pregnancy, simply for the 
reason that there is not a tittle of evidence that there is anything to be antago- 
nized. The body quietly suffers itself to be distended by the product of con- 
ception, or rather its growth keeps pace with that of the ovum, whilst the neck 
is not at all concerned either in making room for the foetus or barring its es- 
cape. But though the neck be not called on to exert a retentive faculty, it 
holds, nevertheless, the key, if I may so say, which unlocks the uterine cavity, 
by virtue of the relation, of which mention has been made, established between 
it and the body by pregnancy, in consequence of which impressions made upon 
it, specially upon its internal surface, are reflected upon the body and excite 
its muscular fibres to expulsive action. Hence the necessity of keeping the 
neck closed to so late a period of pregnancy, while the body is growing and 
expanding in every direction. That labour is naturally excited in this way, I 
shall endeavour to prove hereafter. The neck is not the active but the passive 
custodian of pregnancy ; it simply withholds the key, until the time to unlock 
the uterus has arrived." 

In respect to the placental connection between the mother and foetus, Dr. 
Miller adopts the views of Weber, that a congeries of colossal capillaries inter- 
vene, into which the utero-placental arteries open, and from which the utero- 
placental veins arise. Against these capillaries, in which the circulation is 
extremely sluggish, the villi of the chorion impinge, and dive, so to speak, as 
they push their growth outwardly; while in such a process they necessarily 
become invested with a covering of the inverted membrane, forming the walls 
of the decidual capillaries. 

As to the uses of the placenta in reference to the foetus, Dr. Miller re- 
marks : — 

"First : It is its organ of respiration. The umbilical vessels, already described 
as terminating in capillaries upon the dendritic processes of the chorion, belong 
exclusively to the vascular system of the foetus. They consist, as we have seen, 
of three trunks, two arteries, and one large vein — a branch of the inferior vena 
cava — and have no communication whatever by anastomosis with the blood- 
vessels of the mother. The arteries convey no inconsiderable portion of the 
blood of the foetus to the placenta, which, after circulating freely and minutely 
through it, is returned to the foetus, not a drop passing into the vessels of the 
mother. While circulating in the placenta, this blood is brought in contact 
with the blood of the mother, flowing through the canals of the maternal por- 
tion of the placenta, or at least nothing intervenes but the thin walls of these 
canals, and the delicate coats of the foetal capillaries. The foetal blood is thus 
enabled to abstract oxygen from, and impart its superfluous carbon to, the blood 
of the mother ; and although it may be supposed that this vital operation is 
not as freely performed as in animals that inhale atmospheric air, it is at least 
as advantageous an arrangement as the branchial respiration of such as inhabit 
the waters, to which it is, in fact, analogous — fishes getting their oxygen from 
water, and the foetus from maternal blood." * * * 

" We have abundant proof that the foetal blood is aerated in the placenta, in 
the consequences that arise from compression of the cord to such a degree as 
to arrest the circulation of the blood in its vessels. Such compression is liable 
to happen, during labour, when the cord prolapses before the head of the child, 
in vertex presentations, and also while the head is passing through the pelvis, 
in nates presentations ; and whenever it does, death is the consequence, while 



184 



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both the celerity and manner of death show clearly that it is caused by suffo- 
cation. The cord ceases to pulsate, and the foetus, after a short convulsive 
struggle, evinces no further indications of life. 

" Secondly: The placenta is the organ through which the foetus derives its nour- 
ishment from the mother. Of this, it must be confessed, there is no positive 
evidence ; but, at the same time, it may be safely affirmed that, in relation to 
this point, negative evidence is altogether satisfactory. There is absolutely no 
other medium through which the foetus can obtain its supplies of alimentary 
matters. The only other possible source is the liquor amnii, the fluid which 
surrounds the foetus ; and the doctrine that this is appropriated, either by ab- 
sorption or deglutition, has long since been exploded, by facts and arguments 
that cannot be answered, which need not be rehearsed in this place. How or 
in what form nutriment is received through the placenta is not known ; most 
probably there is a set of vessels, in connection with the umbilical capillaries, 
which open into the maternal portion of the placenta, and, abstracting from 
thence the needful supplies, convey them at once into these capillaries, to be 
incorporated with the foetal blood. Whether these hypothetical vessels take 
up blood, or only certain of its elements, we do not know ; nor, as far as I can 
see, is it a matter of the least practical moment that we should know. Nature 
here, as elsewhere, is chary of her revelations that might gratify the curiosity, 
without adding to the resources of her votaries/' 

In treating of the position of the foetus in utero, and the cause of the great 
preponderance of vertex presentations, Dr. Miller enters into a somewhat ex- 
tended exposition of the facts which disprove the generally received mechanical 
explanation, that it is due to the weight of the head, compared with that of 
the rest of the body, at all stages of foetal development. He adopts the views 
of M. Dubois, that the cause of the greater frequency of head presentations 
is in some manner dependent upon the vitality of the foetus, and that the 
position is probably assumed and maintained by the voluntary or instinctive 
movements of the latter. In which views Dr. Simpson also coincides, except- 
ing that he contends the movements on the part of the foetus, in consequence 
of which its head is made to be the most dependent part, in utero, are purely 
of a reflex or excito-motory character. 

All this, however, is but mere hypothesis. The most usual intra-uterine 
attitude of the child, with its limbs flexed and folded upon its body and its 
head dependent, shapes it, if we may be allowed the expression, into a form 
exactly adapted to that of the uterine cavity, while it is the one most favour- 
able to the mechanism of labour. We may, therefore, safely conclude that it 
is the one impressed upon the foetus by the same vital laws which govern 
everything that relates to intra-uterine gestation. The exact forces by which 
it is effected are beyond our ken, as well as those which occasion the frequent 
deviations from what may not improperly be assumed as the normal foetal 
position and attitude. 

The subject of abortion very naturally follows that of pregnancy. Dr. Mil- 
ler denies the position of Dr. Meigs, that the hemorrhage which is the invaria- 
ble concomitant of abortion proceeds from the placental surperficies of the 
womb, and always implies a detachment of the placenta to a greater or less 
extent. He maintains, and we think with great show of reason, that it is 
derived chiefly from the decidual vessels, probably, from both layers of the 
decidua, and that it may proceed from any point of the ovum or the inner sur- 
face of the uterus. He believes that in abortion the hemorrhage is often 
pathological rather than traumatic in its nature, the result of decidual hype- 
remia — an exudation from the distended and overloaded bloodvessels of the 
decidua, without rupture. 

" This may be inferred," he remarks, " from the fact that a sense of fulness 



1858.] Miller, Principles and Practice of Obstetrics. 



185 



and weight is not unfrequently complained of previous to the eruption of blood, 
and also the further fact that the hemorrhage may precede the uterine contrac- 
tions, and is always coeval with them, even in their incipiency, when they are 
too few and feeble to disturb the relations of the ovum to the internal surface 
of the uterus." 

As to the causes of abortion, Dr. Miller, after enumerating the usual acci- 
dental causes, febrile diseases, drastic purgatives, and diseases of the ovum re- 
sulting in the death of the foetus, concludes that, whatever influence these 
may have in bringing on abortion in the case of a perfectly healthy uterus, 
the most prolific cause of the expulsion of the ovum in the early months of 
pregnancy is a diseased condition of the uterus itself, particularly inflamma- 
tion of the uterine mucous membrane, either of the cervix or body. 

" Inflammation of the mucous membrane of the body of the uterus may, doubt- 
less, directly excite contractions which shall expel the ovum, just as inflamma- 
tion of the intestinal mucous membrane may directly excite increased peristaltic 
movements which shall expel the feces ; but when the inflammation is limited 
to the cervix uteri (and this is most frequently the case), it acts as an abortive 
through the medium of the relation existing between the neck and body of the 
organ, alluded to in a previous chapter, by virtue of which impressions made 
upon the cervical nerves are reflected, through the spinal cord, upon the mus- 
cular fibres of the body and fundus, exciting them to contraction." 

But, according to Dr. Miller, it is endo-uteritis more than inflammation 
of the cervix which exercises a morbid reaction on the ovum. When the 
mucous lining of the body of the uterus is involved in disease. 

" It may be either altogether incapacitated to undergo transformation into the 
deciduous membrane or an imperfect metamorphosis of it may be the conse- 
quence. In the first case, abortion, and that speedily, must ensue, for the ovum 
cannot effect an attachment to the uterus, and may be degraded into a mole or 
a mass of hydatids ; in the second, the disease may be communicated to the 
placenta and through it to the foetus, deranging its nutrition and variously af- 
fecting its growth, so as to produce, perhaps, even monstrosities." 

The series of facts and arguments adduced by Dr. Miller strongly impress 
his views as to the dependence of abortion, in a large number of cases at least, 
on inflammation of the lining membrane of the uterus, upon our attention. 
These views are consistent with a host of facts and observations that could 
easily be adduced. That they do not explain all cases of abortion not directly 
attributable to some accidental cause, or to diseased conditions of the system in 
which the uterus is only indirectly implicated, is very certain. There are cases 
of abortion which cannot be traceable to accidental shocks and injuries, to 
violence, constitutional disease, or any appreciable lesion of the uterus, either 
of its body or neck, and which would seem to depend upon some condition of 
the womb by which it is rendered intolerant of the presence of the ovum when- 
ever the latter has arrived at a certain degree of development. At the same 
period, or very nearly so, of each succeeding pregnancy, we have known the 
ovum to be expelled, in patients in whom not a trace of uterine disease could 
be detected upon the most careful, thorough, and repeated examination, and 
who had never suffered from the slightest symptom of leucorrhoea. Whether 
we refer such intolerance of the uterus to abnormal irritability of the womb, 
or some other occult condition of the organ, it is very evidently unconnected 
with inflammation of the lining membrane of its body or cervix. 

Dr. Miller presents a very good account of the resistive and palliative treat- 
ment of abortion, and under the head of its prophylactic treatment enters at 
length into the general subject of the treatment of uterine disease — of cervical 
inflammation, or ulceration, endo-uteritis, and uterine displacements. The 



186 



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[Jan. 



therapeutic directions for the treatment of cervical and uterine inflammation 
and ulceration, in which are discussed the propriety of local depletion from 
the affected part, cauterization of the os uteri, intra-vaginal injections, etc., 
with the circumstances under which each is to be employed, the proper me- 
thod of employing it, and the precautions necessary to its successful manage- 
ment, are all marked by good sense, but differ in no important particular from 
those ordinarily pursued by skilful practitioners. They are deserving, how- 
ever, of a careful perusal on the part of all who are called upon daily to pre- 
scribe for the diseases peculiar to the female sex. 

On the subject of displacements of the uterus, Dr. Miller takes the mid- 
dle ground between those who consider them as invariably the result of inflam- 
mation, and those, on the other hand, who refer them to other causes, but 
consider them, when produced, to be productive of inflammation; he believes 
that they are sometimes a sequence of inflammation and sometimes its cause. 

In relation to Dr. Simpson's pessary for the rectifying of anteversion, re- 
troversion and flexion of the uterus, Dr. Miller holds the following decided, but 
in our estimation, very correct language. 

" This kind of mechanical contrivance for holding the uterus in its proper 
situation appears to me to be the most unphysiological of all others that have 
been proposed. The uterus, in its natural state, possesses great mobility, 
amounting almost to locomotion, by which it is enabled to accommodate itself 
to the various disturbing influences by which it is surrounded. Pressed upon 
by the contractions of the diaphragm and abdominal muscles, during great 
muscular exertions, it descends towards the vulva ; pushed up during coitus, 
its fundus is tilted forwards and its cervix backwards, whilst considerable dis- 
tension of the urinary bladder necessarily retroverts it ; in a word, it readily 
adapts itself to its circumstances, whatever they may be. Now, to rigidly fix 
such an organ upon a metallic axis, and leave it no possibility of escape from 
the thousand impulsions which it daily receives, is to place it in a more unna- 
tural predicament than any malposition can possibly be. The intra-uterine 
pessary is, however, not more unphysiological than unpathological. Rarely is 
inflammation altogether absent in these displacements, and sometimes it is very 
intense; to irritate the uterus, in such a state, by thrusting a foreign body into 
it to compel it to keep its place is a species of surgery which would not be tole- 
rated in the outward parts. That some of Prof. Simpson's patients should not 
have been able to bear his pessary is not surprising ; the wonder is that any of 
them could bear it, whilst it is a miracle that many of them got well." 

" After all, the intra-uterine pessary fulfils its indication — albeit it performs 
its duty somewhat too sternly — that is, it keeps the uterus in the place allotted 
it by obstetric authority, with its metallic axis coincident with the axis of the 
pelvic brim. And this is more than I am warranted to say in favour of any 
other pessary that has been recommended for retroversio uteri, not even except- 
ing Prof. Meigs' elastic annular pessary, so much lauded by him." 

" If it should be inferred from the foregoing remarks that I have but a poor 
opinion of pessaries, the inference would be logical and just, for though I have 
tried all kinds of pessaries, not excepting Dr. Simpson's, I have derived but 
little benefit from them, whilst they have been a fruitful source of vexation to 
myself and of annoyance to my patients. As, however, I have admitted the 
validity of the indication to restore the uterus to its natural position, it maybe 
reasonably demanded, if pessaries are unavailing or mischievous, how is the 
indication to be accomplished ? After I had discarded pessaries in the treat- 
ment of endo-uteritis complicated with retroversion, I was led to conjoin re- 
peated replacement of the uterus by the sound and cauterization of its cavity, 
whilst the organ is in situ, and by this method of treatment, which I may ven- 
ture to call my own, have obtained more satisfactory results than by all other 
methods which I had previously tried." 

The subject next treated of is the flooding of advanced pregnancy and in- 



1858.] 



Miller, Principles and Practice of Obstetrics. 



187 



cipient parturition. This accident forming, as it were, " a fit connecting link 
between the study of pregnancy and parturition." 

These floodings are invariably the result of a detachment, to a greater or 
less extent, of the placenta from the inner surface of the uterus ; the pla- 
centa in a large proportion of cases being abnormally situated at the mouth, 
as it is commonly expressed, of the womb. This circumstance leads of course 
to a consideration of the subject of placenta prsevia, it being one immedi- 
ately connected with the pathology of the floodings that are liable to occur 
during the latter months, or at the close of pregnancy. It is true that, ac- 
cording to our experience, accidental hemorrhage, that is, hemorrhage resulting 
from a partial or entire separation of the placenta, its position being normal, 
is of much more frequent occurrence than that dependent upon placenta 
praevia, nevertheless the consideration of the latter in the present connection 
is, we consider, most appropriate. 

To acquire a correct notion of the nature of placental presentations, it is 
necessary to recollect that, " during the first six months of pregnancy, the cer- 
vix uteri preserves its cylindrical figure and keeps both its orifices, but espe- 
cially the superior, tightly closed ; it is plain, therefore, that the placenta is 
implanted originally over the cervix, but attached, nevertheless, to the parietes 
of the inferior part of the body of the uterus. It is with the body, and the 
body only, that it forms an organic union by the reciprocal passage of blood- 
vessels between them." It is not, and in the nature of the case, never can 
be implanted upon the internal surface of the neck of the womb. This fact 
Dr. Miller has rendered perfectly clear by a course of reasoning which ap- 
pears to us to be irrefutable. 

The mechanism of the hemorrhage which necessarily takes place in cases 
of placenta praevia is explained by Dr. M. from the development of the ute- 
rine parietes occurring more rapidly than the placenta can follow, causing, 
therefore, a separation of the maternal from the foetal tissue, with rupture of 
the connecting vessels. 

From various considerations, but more especially from the analogy of ute- 
rine hemorrhage often occurring under other circumstances of parturition, 
particularly post partem, where the placenta is wholly separated and expelled, 
Dr. Miller concludes that the great source of the hemorrhage, in cases of 
placenta praevia, and in other cases of partial and entire detachment of the 
placenta in the latter months of pregnancy, is the placental surface of the 
uterus itself. 

Besides the unavoidable cause of hemorrhage in cases of placenta praevia, 
other causes that may operate to excite hemorrhage during advanced preg- 
nancy are referred to by the author ; the most frequent of these is perhaps 

" Mechanical violence of any kind, such as falls, blows, &c, sufficiently vio- 
lent to produce detachment of the placenta from its normal connections. Pro- 
bably, also, an excited state of the circulation, especially in plethoric habits, 
may suffice, in some instances, to bring about the same disastrous result. Irri- 
tation of the intestinal canal, whether induced by disease or the operation of 
drastic purgatives, exciting tenesmus and violent straining efforts, may also 
be reckoned among the causes of uterine hemorrhage." 

We have given merely a bare outline of the leading views of Dr. Miller on 
this important subject of flooding — accidental and unavoidable — occurring in 
the pregnant female ; for a full exposition of those views, which certainly de- 
mand a candid examination, and of the considerations upon which they are 
based, we refer to the work itself. The chapter devoted to the consideration 
of the subject of flooding, will amply repay the time devoted to its attentive 
study. 



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A very full and instructive account is given of the symptoms, diagnosis, 
course, and termination of flooding. In respect to treatment : in cases of 
accidental hemorrhage, Dr. Miller advocates the plan pursued by Puzos, 
a description of which, as it would appear not to be generally understood, we 
here present in the translation furnished us by our author. 

" The means of remedying this slowness of natural delivery, is to borrow 
something from forced delivery, which, I am satisfied from experience, is en- 
tirely practicable — namely, to increase the dilatation of the os uteri with the 
fingers, in the same gentle manner in which nature is wont to proceed. It is 
seldom that the loss of blood, produced by the detachment of the placenta, 
does not occasion more or less dilatation of the uterine orifice, the coagula 
about it acting as so many wedges, that distend it and dispose it to yield. This 
incipient dilatation has a tendency to bring on labour, and is sometimes accom- 
panied by slight pains. But, inasmuch as the exhaustion and faintness arising 
from the loss of blood are opposed to the continuance of the uterine contrac- 
tions, we must renew these when wanting, and increase them when too feeble. 
With this view, one or two fingers must be introduced within the os uteri, 
which is to be gradually opened by the employment of force proportioned to its 
resistance. These dilating efforts should be suspended from time to time, to 
allow intervals of rest. By this means, the uterus is roused to action, labor 
pains come on, and the membranes are rendered tense. The next object is to 
rupture the membranes without delay, to give escape to the liquor amnii, and 
bring about a diminution in the size of the uterus equal to the space the waters 
had occupied. The condensation of the uterus, that succeeds the discharge of 
the liquor amnii, presses the foetus upon the os uteri, when stronger pains 
ensue, which, aided by the pressure of the fingers around the margins of the 
orifice, succeed in advancing the child. Meanwhile, the blood that would other- 
wise have escaped, is retained in the vessels by the contraction of the uterine 
fibres, and the compression to which they are subjected. By this co-operation 
of nature and art, the delivery is greatly expedited, and we may enjoy the 
satisfaction of saving both mother and child, who must have been lost if left 
to nature alone, and might have been destroyed by artificial delivery." 

In cases of unavoidable flooding, from partial presentation of the placenta, 
experience, Dr. Miller assures us, has equally declared in favour of the effi- 
cacy of Puzos' plan of management. Where the placenta is implanted cen- 
trally over the mouth of the womb, some modification of the plan is, however, 
demanded. In these cases Dr. M. is opposed to the artificial separation of 
the placenta from its attachments, as proposed by Simpson and strongly ad- 
vocated by others. He enters into a long chain of reasoning to show that 
whether considered in a scientific point of view, or tested by the results of the 
practice, so far as these have been made known, it does not present such strong 
claims as to warrant its being generally pursued. He is equally adverse in 
vertex presentations, in view of the unfavourable results that are so frequently 
observed in the cases in which it has been practised, to a resort to turning 
and delivery by the feet. The plan he ventures to propose is a modification 
of that of Puzos. This consists in " originating expulsive contraction of the 
uterus by the tampon or plug, and then puncturing the membranes, relying 
on the tampon to control the flooding until the liquor amnii is evacuated." 

" This," he remarks, " is the only method of treatment of which I have any 
experience, and I have employed it with uniform success, so far as the mother 
is concerned. This is strong testimony, but it must be mollified by the con- 
fession that my experience, in placenta praevia cases, has not been large; yet 
I have encountered them sufficiently often to have acquired some acquaintance- 
ship. 

" To expound this method of treatment and at the same time vindicate it, 
it must be observed that the tampon is preferable to manual dilatation, as an 
oxytocic, in placental presentations, because forced dilation could not be prac- 



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Miller, Principles and Practice of Obstetrics. 



189 



tised without necessarily still further detaching the placenta, giving rise to 
additional hemorrhage, all the more profuse on account of the non-parturient 
state of the uterus. Then, again, such manipulations would be objectionable 
because of the greatly more vascular and sensitive condition of the portion of 
the uterus contiguous to the os, which has been already mentioned as a reason 
why delivery by turning ought to be refrained from. 

" In arousing the uterus to expulsive contraction, the tampon acts, I sup- 
pose, through the channel that has been more than once indicated in the pre- 
vious pages of this work, viz : irritation of the incident nerves of the cervix, 
leading to reflex action of the fibres of the fundus and body. Explain as we 
will, however, the fact is generally admitted that the tampon is competent to 
excite uterine contraction and bring on labour. Should it fail (and what may 
not ?) it may be reinforced by the puncture of the placenta, as recommended 
by M. Gendrin, which, considered merely as a means of bringing on labour, 
is excellent and wholly unexceptionable, and it will be observed that I am not, 
just now, speaking of the restrainment of hemorrhage, but of the excitement 
of labour. No case can occur, I think, in which the tampon, aided, if neces- 
sary, by puncture of the placenta, will fail to bring on labour, in a longer or 
shorter time, and where the tampon alone is sufficient, and labour is regularly 
established by its instrumentality, either the placenta must be punctured to 
evacuate the liquor amnii, or the finger must be pushed up beyond its margin 
to rupture the membranes during a uterine pain. I have myself usually prac- 
tised the latter alternative, and always felt that my patient was safe when ad- 
vanced thus far on the road to recovery. 

" The supervention of labour — the evacuation of the liquor amnii — these, in 
their order, are the great bulwarks of a flooding woman, no matter where the 
placenta is implanted. It is a maxim in obstetrics that a contracted uterus 
cannot bleed ; it might, I think, be amended and enlarged by adding that 
neither can a contracting uterus bleed when it is emptied of its waters — or at 
any rate, if it bleed, the hemorrhage is no longer dangerous. 

"Notwithstanding that the tampon may be generally depended on to re- 
strain hemorrhage, it is certainly possible that it might disappoint our expecta- 
tions, and then the evacuation of the amniotic fluid by placental puncture may 
be had recourse to, as an auxiliary, on the authority of M. Gendrin. Should 
this fail, and the hemorrhage threaten to destroy the mother ere uterine con- 
traction can be excited, there can be no doubt of the propriety of separating 
and extracting the placenta, according to the letter of Dr. Simpson's proposal, 
viz: solely with a view to the safety of the mother, losing sight of the child, 
whose interests are altogether subordinate. Such a procedure excludes, of 
course, delivery by turning, by which, as it has been shown, many maternal 
lives have been sacrificed that might have been saved, had the expulsion of 
the child been left to nature." 

The subject of labour is next considered. We do not intend to follow the 
author in his very excellent examination of the efficient and determinative 
causes of labour, and the forces which co-operate in the expulsion of the con- 
tents of the gravid uterus. The entire chapter devoted to this branch of 
obstetrical physiology is replete with interesting views which demand a favour- 
able consideration, and which, whether received throughout as established 
truths, or as merely plausible hypotheses, cannot fail to point the road to a 
more correct and intimate acquaintance with the subject. 

Dr. Miller teaches that the real cause of the occurrence of labour at the 
completion of uterine and foetal development, is that suggested by Dr. John 
Powers, the irritation, namely, of the cervix, and especially of the os uteri, 
arising from the contact, which then takes place, of the ovum with the latter. 
This he supposes to be proved, 1st, by the peculiar manner in which the 
uterine neck is unfolded during pregnancy, and 2dly, by the fact that the 
rectum and bladder are both excited to expel their contents by irritation of 
their orifices. The objections that have been made to this theory are candidly 
No. LXIX.— Jan. 1858. 13 



190 



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[Jan. 



examined, and, with much apparent plausibility, refuted. To understand the 
real value of the cause assigned by Dr. M. for the inception of labour, regard 
must be constantly had to the true relationship of the condition of the neck 
of the uterus to that of its body at the different stages of pregnancy. 

The phenomena of labour are the subject of the following chapter. They 
are clearly and fully detailed in the order of their occurrence. 

In regard to the utility of the membranes, or pouch of waters, as it has 
been termed, both before and after the protrusion of a portion of the pouch 
at the uterine orifice, as a means of promoting the expansion of the os uteri 
and facilitating the progress of labour, Dr. M. makes the following sensible 
remarks. There is, it is true, nothing especially novel in them, corresponding 
as they do with the experience of nearly all skilful and observant practition- 
ers. It may not, however, be improper to call attention to them on the part 
of the younger members of the obstetrical corps, inasmuch as their validity 
has been denied, and there are even some who incorrectly suppose that the 
premature rupture of the membranes and discharge of the waters will not 
tend to retard labour, or render it more painful. Some have even pretended 
that their early rupture will often facilitate and shorten it. That these latter 
positions are incorrect, Dr. Miller believes is shown by the following consider- 
ations : — 

" First. The integrity of the membranes before the pouch is form*ed is valua- 
ble, because the propelling force has then a more suitable medium wherewith 
to act on the cervix than any part of the foetus would be. This medium is the 
waters inclosed by the membranes, which, adapting themselves to the shape 
and inequalities of the cervix, make more equable pressure on its fibres, and 
consequently subdue their resistance more equally ; whereas any part of the 
child that can present is not so well adapted to distend the cervix equally, and 
hence, while some of its fibres may be benumbed by pressure, others are not 
conquered, but provoked to inordinate resistance, thus retarding labour by the 
irregular contraction which is excited. 

" Secondly. The integrity of the membranes, after the pouch is formed, is 
beneficial until the dilatation of the os uteri is considerably advanced, if not 
completed ; because the pouch, though it does not cleave like a wedge, opens 
the portals for the egress of the child in the gentlest manner. Should it rup- 
ture before the orifice is prepared to allow the presenting part of the child to 
take its place, the ruder contact that ensues not unfrequently irritates the cer- 
vix to a renewal of its opposition, and labour is thus protracted and rendered 
more painful. 

" Thirdly. The pouch serves, by its presence in the uterine orifice, the most 
sensitive portion of the neck, to sustain and enliven the propelling contrac- 
tions, upon the principle of orificial irritation. By its agency, these contrac- 
tions are, in proper time, rendered truly expulsive, and the auxiliary forces of 
the diaphragm and abdominal muscles called into action. When the pouch 
ruptures, the presenting part of the child takes its place, and keeps up the 
requisite grade of irritation until the labour is completed. That this is no 
fancy sketch, the phenomena of shoulder presentations will abundantly prove. 
In these cases, the membranes frequently protrude in the form of a long, cylin- 
drical purse, which inadequately stimulates the os uteri, and consequently the 
pains are feeble for an unusual length of time; and when at length they rup- 
ture, if the shoulder is not ready to occupy the orifice, as often happens, there 
is an entire suspension of the pains for several hours." 

In proceeding to a consideration of the mechanism of labour, the several 
presentations and positions of the foetus in utero are first described. The 
classification of these as adopted by Duges, is the one followed by Dr. Mil- 
ler. The mechanism of labour in each of these is separately discussed. To 
the subject all that extension is given which its importance demands. With- 



1858.] 



Miller, Principles and Practice of Obstetrics. 



191 



out a clear conception of the manner in which the foetus, in each case, is 
transmitted through the pelvis, the course it takes, and the successive changes 
which occur in the condition and direction of the presenting part, as it is 
gradually propelled from the womb into the world, no one is competent to 
conduct properly and safely the most simple and easy case of parturition, 
much less to act promptly and efficiently in cases attended with delay or 
difficulty, or in which manual or instrumental interference is required to in- 
sure the safety of the mother or child, or both. 

In the chapter devoted to this subject the views and explanations of the 
most authoritative masters in midwifery are laid down, but not implicitly 
followed. Dr. Miller has had the courage to examine and judge for himself, 
and to express his own conclusions, however these may differ from those of 
others. His explanatory and critical remarks appended to the account given 
of the mechanism of labour in each presentation are marked by much good 
sense. We have perused them with both pleasure and profit. 

In the ensuing chapter on the diagnosis and prognosis of labour, a very 
good account is given of the means of ascertaining whether labour has actually 
commenced or not, and, when it is found that labour has actually set in, the 
manner in which the presentation and position of the child are to be deter- 
mined, with some very judicious remarks on the prognosis of labour gene- 
rally, and in each of the several presentations and positions. 

It is very certain that in respect to the prognosis of labour, considered as 
to its probable duration, its favourable termination if left to the powers of 
nature, and the necessity for instrumental interference, there can be but few 
positive rules laid down that will admit of universal application. From close 
observation, the experienced practitioner acquires a certain tact by which he 
is able to form in each case of labour a very accurate judgment of its proba- 
ble course, and to infer its favourable or unfavourable termination if left to 
itself. But this tact can scarcely be taught by books or oral instruction : it must 
be acquired from clinical experience, and from that only by such as have made 
themselves intimately acquainted with the form, structure, planes, axes, and 
normal dimensions of the pelvis, the anatomy and admeasurements of the 
foetus in utero, and the physiology and mechanism of labour according to the 
presentation and position of the child, as well as with all those causes that 
may increase the pain of parturition, retard or arrest its' progress, and the 
particular dangers incurred by mother or child, or both in cases of tedious, 
difficult, and obstructed labour. It is true that there are many cases in 
which the danger of trusting the accomplishment of delivery to the unaided 
powers of the uterus, or the impossibility of the birth of the child without 
manual or instrumental assistance, can be determined with almost positive 
certainty. The general rules by which the diagnosis and prognosis of such 
cases are governed are clear and explicit ; ignorance of them would be highly 
culpable in any practitioner of midwifery. 

The retarding and impeding causes of labour as they present themselves in 
its different stages are treated of by Dr. M. in his chapter on the management 
of labour. They are, in the first stage, obliquity of the uterus; the ineffi- 
cient or impeded action of the organ; rigidity of the os uteri; and, in the 
second stage, inefficient and impotent action of the uterus. 

In cases of obliquity of the uterus, Dr. M. insists upon the importance of 
restoring the os uteri to its natural position. 

" This," he teaches, " may generally be effected by regulating the posture 
of the patient, enjoining her to lie on the side opposite that, towards which the 
fundus inclines." When anterior obliquity exists, in a great degree, a properly 



192 



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[Jan. 



adjusted bandage around the abdomen will materially contribute towards re- 
storing the uterus to its natural situation. 

" Should strict attention to posture, continued for a reasonable time, fail to 
correct the obliquity, and the labour in the meanwhile make but tardy pro- 
gress, it is proper to hook the os uteri by inserting the extremity of the finger 
within its orifice, and draw it towards the centre of the pelvis, in the intervals 
of the pains. When a pain comes on, its tendency to relapse to its former 
position is to be resisted, with as much force as can be safely employed. If 
this tendency is too powerful to be resisted, the finger must yield to it ; but, 
as soon as the pain ceases, bring back the os uteri to the centre, and again en- 
deavour to maintain it there during the next pain. By cautiously and gently, 
but perseveringly, acting thus, the os uteri will, after a succession of centri- 
petal and centrifugal movements, be restored to its proper place, and, the par- 
turient forces having been brought to bear upon it, its dilatation will be effected 
as speedily as in ordinary cases.-" 

"In deliberating upon the propriety of artificial aid, in cases of obliquity of 
the uterus," Dr. M. believes that, " the ability of nature ultimately to overcome 
the difficulties which they offer, should not be taken into consideration. The 
primary question is, can obliquity seriously retard labour ? and this has been 
answered in the affirmative, even by Dr. Hunter, in his commendation of pa- 
tience, but less equivocally by Dr. Denman and others of the same sect. Obli- 
quity ought, then, to be remedied in all cases, when it unduly protracts the 
first stage of labour, if the principles of Dr. Hamilton should govern our con- 
duct. Labours, rendered tedious from this cause, may undoubtedly hobble to 
their end, even to the expulsion of the foetus in some way — nevertheless all the 
mischiefs that grow out of delay, are justly chargeable to the obliquity, and 
might have been averted, had it been remedied." * * * 

Awkward and unskilful attempts at rectification of the obliquity may, Dr. M. 
admits, produce inflammation of the uterus, but this, he remarks, is chargeable to 
the operator, not to the operation, which need not cause pain, much less any such 
serious consequences. "For my own part/' he adds, " I can safely declare that 
no mischievous effects of any kind have ever resulted, in my practice, from such 
tractions upon the os uteri as have been recommended, and the testimony of 
Dr. Dewees is equally decisive in regard to their safety and efficacy. Nay, this 
eminent practitioner deemed them of so much importance as to advise the in- 
troduction of the entire hand, well lubricated, into the vagina, in order to get 
hold of the os uteri with the finger, when it cannot be reached by a well- 
directed search in the ordinary way ; and, under the circumstances that he 
has specified, I should not hesitate to follow his advice, although I have not as 
yet had occasion to do it." 

In cases of inefficient action of the uterus the proper course, according to 
Dr. M., is, if any morbid state of the system can be reasonably assigned as 
its cause, to correct it ; if the pulse is full and strong, blood should be ab- 
stracted ; if the bowels are confined, they ought to be relieved by an enema, 
or a dose of castor oil. But if these means fail, or not being indicated, are 
not resorted to, the proper remedy is, irritation of the uterine orifice oy means 
of the finger, for the purpose of exciting more efficient contractions of the organ. 

After describing the mode of effecting this irritation, he remarks : — 

" Speaking from abundant experience, I can truly say that it is equally sur- 
prising and gratifying to observe the prompt effects of this manipulation, in 
many cases of the kind under consideration. Not unfrequently, a few move- 
ments of the finger are sufficient to impart such energy and aim to the uterine 
contractions, that the waters begin to gather, as the phrase is, and cause the 
membranes to protrude." 

Dr. M. states that he has been in the habit for many years of employing, 
under the circumstances indicated, the manipulations he has described, and 
in the great number of cases in which they have been practised no evil con- 
sequences whatever have resulted, but labour has been greatly assisted, and 



1858.] 



Miller, Principles and Practice of Obstetrics. 



193 



many accidents, as he is firmly persuaded, have been averted, which would 
otherwise have happened from its undue protraction. 

The chief course of impeded action of the uterus during the first stage of 
labour is, according to our author, premature rupture of the membranes. In 
the treatment of tedious labour resulting from this accident, he recommends 
if the os uteri be hot, tender to the touch, and rigid as well as tumid, the 
free detraction of blood. He believes, however, that the judicious employ- 
ment of the fingers in aid of the uterine contractions is much more frequently 
indicated, and is often the only thing that can be done to assist the patient. 

"The fingers are not to be used," he observes, "to excite uterine contrac- 
tions (for they are already too strong), nor to stretch the os uteri, but to press 
upon its margin, during the pains, in order that their counter pressure may 
keep it in as firm contact with the head as the rest of the cervix, and the ori- 
fice be thus brought within the pale of the dilating influence of the uterine 
contractions. Both Hamilton and Gooch highly recommend this practice, but 
their object is to push up the edge of the orifice over the head of the child ; to 
liberate the band of the cervix, supposed to be incarcerated — a condition which, 
if it really existed, could scarcely be reached by such a procedure." 

In cases of rigidity of the os uteri, Dr. M. recommends copious bloodlet- 
ting, opiate enemata, the administration of tartarized antimony, the local 
application of extract of belladonna or of stramonium to the os uteri, tepid baths 
and demi baths. Should all of these means fail, or but partially succeed in 
overcoming the rigidity of the os uteri, and the cervix descend in advance of 
the head of the child, it is necessary, he remarks, to raise and support the os 
uteri. 

" As this is a measure of considerable importance, I shall endeavour," says 
Dr. M., "to explain how it is to be practised. The index finger is to be ap- 
plied just underneath the anterior lip of the os uteri, and with its edge or 
palmar surface pressure is to be made, in the intervals of the pains, so as to 
push up the os uteri as high as possible, or the extremities of two or three of 
the fingers may be used in the same way. When a pain comes on, the tendency 
to descent is to be resisted, unless this be so strong as to require more force 
than it would be prudent to employ ; in that case, the finger must gradually 
relax its counter-pressure and allow the descent to take place. But as soon as 
the pain goes off, the os uteri is to be pushed up again, and its descent is again 
to be resisted during the next pain. In this manner, acting with gentleness 
and caution, but, at the same time, with firmness and perseverance, the os 
uteri must be supported until it is sufficiently dilated to allow the head to exe- 
cute its rotatory movement, and emerge from under the symphysis pubis. 

" The principle upon which this manoeuvre acts does not appear to have been 
well understood, even by those who have practised it. The support given to the os 
uteri prevents it from prolapsing, to be backed, if the expression will be allowed, 
by the floor of the pelvis, and places it in a position that will permit a portion 
of the head to become insinuated within it during a pain. The finger is not 
used to stretch the os uteri, as many writers direct, but to hold it up that it 
may be dilated by the head, which can then be pushed, by the uterine contrac- 
tions, lower than the level at which the os uteri is held. The head dilates the 
os uteri far better than the finger could, because it acts upon the whole extent 
of the cervix, whereas the finger could act only on the circle of the os uteri." 

In the second stage of labour, it is a fixed rule of practice with Dr. M. in 
all cases, without exception, to rupture the membranes, when, the dilatation 
of the os uteri being completed, the pains become expulsive, or even in the 
absence of expulsive pains with a view to excite them. The rule we think a 
good one. 

It is in this stage that Dr. M. considers the production of anaesthesia by 
the inhalation of chloroform to be a boon of inestimable value to the partu- 



194 



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[Jan. 



rient female by annihilating the pangs of childbirth, and thus removing the 
"certain fearful looking for" of its ordeal, by which the parturient female is 
so liable to be tormented. 

" I have been in the habit/' he says, "of employing etherization in my ob- 
stetric practice, for nearly ten years, in natural as well as in difficult labours, 
and during that period, must have given it in several hundreds of cases, and I 
am not aware that mischievous effects have followed in a single instance. I 
have occasionally known it to diminish the energy of the uterine contractions 
and lengthen the intervals between them, to such a degree as to make it expe- 
dient to suspend its use for a time, or altogether to discontinue it. But in 
these exceptional cases, no harm resulted, and when the anassthesia passed off 
— which it did in a short time — the labour resumed its course and progressed 
as though it had suffered no interruption." 

" The relief afforded by etherization is not confined," he adds, "to the par- 
turient state ; it extends also to the puerperal state. I have often been struck 
with the remark, spontaneously made by patients who had been previously de- 
livered without the benefit of chloroform, that they felt very much better than 
after their former confinements, having little or none of the muscular soreness 
and stiffness, or the fatigue and exhaustion which before they were accustomed 
to feel — and I think I may safely say that their convalescence is altogether 
better." 

Dr. Miller very properly presents in strong relief the dangerous conse- 
quences that almost invariably happen to the child as well as to the mother 
by the imprudent administration of ergot to overcome the inefficient action 
of the uterus that may occur during the second stage of labour. There can 
be no doubt that, provided the os uteri is dilated, the vagina and vulva re- 
laxed and moist, the presentation natural or such as to offer no great impedi- 
ment to the birth of the child, that it is the vertex, face, or nates that pre- 
sents, and there is no disproportion between the presenting part and the 
pelvis — ergot, judiciously administered, will seldom fail to excite powerful 
uterine contractions by which the child will be promptly expelled. But if all 
these conditions for a prompt termination of the labour are not present, it is 
very certain that the powerful and continued contractions of the uterus pro- 
duced by the ergot, may prove destructive to child or mother, or both. 

As it is not always an easy matter to decide confidently that all the con- 
ditions exist, which justify the exhibition of ergot, whenever there is a doubt 
upon this point, ergot should be withheld, while, according to Dr. M., the 
same manipulations that are recommended by him in cases of inefficient 
action of the uterus in the first stage of labour, may be had recourse to, and 
with marked effect. 

In forming our opinion as to the necessity of artificial delivery in cases of 
impotent action or inertia of the uterus, occurring from exhaustion, the result 
of the long-continuance or severity of the parturient efforts, Dr. M. very cor- 
rectly remarks that our attention should be directed to the evidences of ute- 
rine impotency; in proportion as these thicken, the necessity of delivery 
becomes more and more urgent. 

" It is not wise to wait until the urgency is extreme ; and, in general, the 
earlier the woman is relieved by delivery the better, provided this can be done 
with facility and safety. Suppose, for example, the head of the child is pre- 
senting and has ceased to advance, while the uterus has evidently become im- 
potent ; suppose, moreover, this head is within easy reach of the forceps, and 
can be delivered without risk or additional pain to the mother — what would be 
the use of waiting until we are driven to the operation? But if delivery be 
not so easily and safely practicable, prudence requires that it should be de- 
ferred until the necessity of it is more pressing — so pressing that, in our judg- 



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Miller, Principles and Practice of Obstetrics. 



195 



ment, it is better to incur whatever risk the operation may involve, than wait 
longer." 

The remaining chapters of the treatise are devoted chiefly to an account of 
instrumental delivery. The teachings of the author on this most important 
branch of practical obstetrics are, in the main, sound and judicious, while his 
directions are clear, simple, and precise, and well calculated, so far as it is 
possible by printed instructions, illustrated by well executed engravings, to 
point out, in the several cases and conditions in which instrumental aid is 
required to terminate labour, the manner in which that aid is to be applied — 
in a word, the proper application and management of instruments for the 
delivery of the child in each presentation and position. 

Under the head of delivery by the crotchet, or craniotomy, Dr. Miller dis- 
cusses the question as to the necessity of promptly relieving the uterus of its 
contents upon the occurrence of puerperal convulsions. He admits that, in 
these cases, bloodletting early performed is of great value, indeed indispensa- 
ble, as a means of protecting important vital organs, particularly the brain, 
against the dangerous congestions which are consequent upon the convulsions, 
as evinced by the swollen veins and turgid features during the paroxysms, 
but he insists,- and very properly, that it is futile as a means of arresting the 
convulsions. He consequently condemns the lavish waste of blood by large 
and repeated bleedings, which have been deemed, by many, essential, in cases 
of puerperal convulsions, to the safety of the patient, as not only useless but 
absolutely mischievous. 

Having depleted to an extent sufficient to put the bloodvessels in the best 
possible state to bear the stress laid upon them by the successive convulsive 
paroxysms, which should be done as early as possible, Dr. M. believes that 
the lancet has performed all that it can do, and we must look to other means 
to insure the safety of the patient. The most important and imperative of 
these means, according to Dr. M., is the prompt delivery of the child. So 
important does he consider this measure to be, that he believes it is the posi- 
tive duty of the obstetrician in cases in which the forceps cannot be applied, 
from the early period after the setting in of labour at which the convulsions 
occur, to deliver by craniotomy, whether we have complete assurance or not 
of the death of the child. 

"For this operation," he remarks, "it is not necessary that the os uteri 
should be so largely dilated as for delivery by the forceps, or even by turning 
the child, and hence it enables us to evacuate the uterus, and abrogate the 
cause that sustains the convulsions many hours earlier than it would be possi- 
ble to apply the forceps. 

"It is not recommended," he adds, "to have recourse to craniotomy in 
every case of parturient convulsions so soon as the operation is practicable. 
Not so ; for it may be that there is no such urgent and instant necessity as to 
justify the operation. But if it be otherwise, and there are just grounds for 
our worst apprehensions, whilst, from the tedious manner in which the dilata- 
tion of the os uteri is going on, it is wholly uncertain how long we must wait 
before delivery can be accomplished by the forceps, then the perforator should 
be used, even if the child be alive." 

Now, we candidly confess that we are not so well convinced, that, in any 
case of puerperal convulsions, the necessity for prompt delivery is ever so 
imperative as to justify the sacrifice of the unborn child for its accomplish- 
ment. It is very certain that by etherizing the patient, the convulsive parox- 
ysms may be so completely controlled as to allow, in perfectly natural labours, 
sufficient time for the birth of the child to be accomplished by the unaided 
powers of the uterus alone \ sufficient time, certainly to permit at least, the 



196 



Reviews. 



[Jan. 



os uteri to become so far dilated and relaxed as to allow of the application of 
the forceps, and that without augmenting the danger of the mother. 

In regard to turning, so as to deliver by the feet, Dr. M., in view of the 
many dangers both immediate or remote, which the operation, however skil- 
fully and cautiously it may be performed, entails upon the mother, more than 
doubts its eligibility, under any other circumstances than that of shoulder- 
presentation, and he is strongly impressed with the belief that it ought to be 
strictly confined to such cases. 

" The object of it then," he remarks, " would be to correct such an aberra- 
tion of the axis of the child's body, as precludes delivery ; not to see-saw this 
axis, according to our whims or crude notions, and bring one of its extremities 
or the other to the os uteri, as best suits our fancy, as if to run our hand up to 
the fundus of the uterus, and gyrate the child in its cavity, were to be reck- 
oned among the pastimes of obstetricy." 

Dr. Miller is not strictly justifiable, we think, in absolutely restricting the 
operation of turning to cases of shoulder-presentation; we, nevertheless, ad- 
mit that it is far too dangerous a procedure to warrant any one having re- 
course to it in any instance in which delivery may be safely accomplished by 
other less objectionable means. 

Cephalic version, Dr. M. believes to be applicable to but a limited number 
of cases of shoulder-presentation, when " the labour is in its first stage — the 
os uteri being barely dilated, the membranes whole or recently ruptured, the 
uterine contractions not very powerful or decidedly expulsive, and the shoul- 
der has not become impacted in the pelvis." He gives credit to Dr. Wright, 
of Ohio, for having given the best and most precise description of the opera- 
tive manoeuvre for the accomplishment of cephalic version in cases where it 
is possible to effect it. It justifies, he thinks, the claim of that gentleman, 
if not to originality, at least to the credit of having more clearly apprehended 
the object to be attained, and of more perspicuously pointing to the proper 
method of attaining it. 

The general conclusions of Dr. Miller in regard to the comparative merits 
of the two plans of version — cephalic and podalic — are as follows : — 

" 1. That in simple cases of shoulder presentation, either cephalic or podalic 
version may be practised, the former being preferable (provided it can be ac- 
complished) on account of the greater probability of saving the child. 

" 2. That, whilst cephalic version is not absolutely impracticable, in com- 
plex and even in complicated cases of shoulder-presentation, it is more difficult 
of performance and fully as dangerous, both to the mother and child, as poda- 
lic version, in one or another of its forms. 

" But granting, for the argument's sake, that cephalic version is, in its ulti- 
mate results, as eligible as podalic version, still I should contend that in com- 
plex, much more in complicated cases, it ought never to be had recourse to, 
because the sufferings of the patient are uselessly protracted by it. Even if 
there be not exhaustion of the uterus, it is impossible to know beforehand, in 
any such case, whether the child will be expelled by the natural powers or re- 
quire to be delivered by instruments, thus subjecting the patient to the com- 
bined hazard of manual and instrumental delivery. 

" To me it seems that cephalic version, under the circumstances we are now 
considering, is an unfinished operation. The patient is made to endure all the 
pain and incur all the risk of manual delivery, for the sake of having the head 
of the child placed where it may be expelled by a second course of labour as 
severe and, perhaps, as prolonged as the first might have been, had the head 
originally presented instead of the shoulder. 

"When a woman has been long in labour, the uterus striving in vain to 
expel the child under a shoulder presentation, the necessities of her condition 



1858.] 



Miller, Principles and Practice of Obstetrics. 



197 



■will not admit of any temporizing expedients or halfway measures ; she needs 
to be delivered, and turning by the feet alone can give us that dominion over 
the labour, which is salutary alike for the mother and the child." 

In the second section of Chapter XVI. will be found some excellent direc- 
tions for the management of asphyxia in new-born infants — as to the proper 
procedure in cases of retention of the placenta from either atony of the ute- 
rus, hour-glass contraction, or morbid adhesion; and, finally, as to the treat- 
ment of flooding occurring subsequent to delivery. On this latter subject, 
the author's views and directions are particularly sound, and cannot be too 
strongly impressed on the mind of the young practitioner. 

Two means usually resorted to for the control of post-partum flooding are 
held in very slight esteem by Dr. M. : we allude to ergot and the tampon. 
Of the first he remarks : — 

"There is no harm in giving the article, provided we put no trust in it. I 
mean to say that ergot might possibly do good ; but that its operation is too 
precarious to justify any one in relying on it, to the neglect of the more certain 
resources which have been pointed out." 

We should be sorry to inculcate any positive reliance on any one means for 
the control of the hemorrhage from the womb occurring subsequent to parturi- 
tion, but we must insist upon the very important aid afforded by ergot in most 
of those cases where, after delivery, an undue discharge of blood is threatened 
or has actually commenced. We know of nothing which will so generally 
excite, and with the same promptness, that complete and permanent contrac- 
tion of the womb on which alone in these cases the safety of the patient 
depends. We say nothing of the beneficial influence of the haemostatic powers 
of the ergot, which are very far from being either problematical or incon- 
siderable. It is its specific properties as an exciter of uterine contraction 
mainly that recommends it as a remedy in post-partum flooding. So import- 
ant a remedy do we consider it in this form of uterine hemorrhage, that we 
believe it should be early administered in every case in which we apprehend 
the occurrence of the accident. 

In regard to the tampon, Dr. Miller remarks :— 

" To attempt to control hemorrhage from an empty and flaccid uterus, by 
plugging the vagina, is highly hazardous. We may, it is true, prevent the 
issue of blood by this expedient, but we can have no assurance that it will not 
continue to pour from the vessels and collect in the uterine cavity, until life is 
exhausted. It is better to contend with an open than a lurking enemy ; for 
though we are fully able to cope with him, we might be circumvented by his 
wiles. Let the blood, then, have an unobstructed channel ; we can, the more 
clearly, discern our patient's danger — which it is folly to hide from our eyes — 
and shall be incited to more earnest efforts to save her from impending death." 

There is much truth in the foregoing remarks. The tampon is certainly 
useless in cases of flooding after labour. Until the cause of the hemorrhage — 
the flaccid state of the uterus — is removed, all attempts to control the external 
discharge of the blood are worse than absurd. Until the^full and permanent 
contraction of the organ has taken place the female is in imminent danger, 
and should not be left by the accoucheur. 

In the preparation of the treatise before us, while Dr. Miller has borrowed 
largely from the standard authorities on the theory and practice of obstetrics, 
he has not implicitly followed any master, even though by common suffrage he 
may be ranked among the most authoritative ; but, observing, reasoning, and 
judging for himself, he has infused into the work so much of his own mind, 
that it may lay very legitimate claims to a certain character of originality 



198 



Reviews. 



[Jan. 



which press it strongly upon the attention of the medical profession of the 
United States. In our examination of its several chapters we have met with 
much more to approve than to condemn — far more in relation to obstetrical 
principles and practical precepts and procedure to which we can cordially 
assent, than of which we have been obliged to doubt or absolutely deny the 
correctness. 

The arrangement adopted by Dr. M. in the present treatise is somewhat 
different from that pursued in most of the standard works on the same sub- 
ject. In some respects it has unquestionably its advantages, but we are not 
so certain that it is the one best adapted for a systematic treatise on obstetrics 
intended for the use of students. 

The style of the work is throughout simple, clear, and sufficiently correct, 
though occasionally marred by colloquial expressions which neither give force 
to the author's meaning nor impressiveness to his practical directions. 

Dr. Miller admits that he has not attempted to introduce into his pages 
" every topic, both large and small, that belongs to obstetrics still, in a 
work professedly aiming " to present, in as condensed a form as possible, an 
exposition of the cardinal principles of obstetrics, considered as a science and 
an art," we should certainly have expected to meet with an account of the 
management of twin cases, and of rupture of the uterus, and some notice at 
least of the important question as to the propriety of the induction of prema- 
ture labour in those cases in which, from deformity of the pelvis, delivery at 
the full term is rendered impossible without the destruction of the child. 
Besides these omissions, we notice, also, the omission of any account of the 
circumstances which will warrant or imperatively demand a resort to the use 
of instruments in cases of labour. Some of these circumstances are, it is true, 
incidentally alluded to in the course of the treatise, but nowhere are all of 
them indicated with that fulness of detail which would seem to be demanded 
by the importance of the subject, the different opinions on many points con- 
nected with it entertained by distinguished obstetricians, and the serious mis- 
takes that are every day made by practitioners, in consequence of the erroneous 
views they have formed in respect to it. 

Without some notice of the several topics just alluded to, no treatise can 
be properly considered as embracing an exposition of " the cardinal princi- 
ples'' of obstetrics as a science and an art. We admit that full accounts of 
them all may be found in other works ; nevertheless, one having similar pre- 
tensions to the character of a systematic treatise on " the principles and prac- 
tice" of midwifery must be considered incomplete without them. There is 
as much necessity for their introduction as for that of the anatomical descrip- 
tion of the pelvis and female organs of generation, and their obstetrical rela- 
tions, which the author admits he has borrowed from the work of M. Dubois, 
and very properly, inasmuch as he there found so good a description that he 
was in some measure compelled to follow it in his desire to give a correct 
account of these subjects considered in an anatomical and obstetrical point of 
view. 

Whatever, however, may be the faults of omission or commission in the 
work of Dr. Miller, it must, nevertheless, be pronounced a most able one, con- 
ferring the utmost credit upon its author, and fully entitled to that favourable 
reception we are well convinced it will, receive on the part of the American 
medical profession. D. F. C. 



1857.] 



199 



BIBLIOGRAPHICAL NOTICES. 

Art. XVII. — Transactions of American State Medical Societies. 

1. Transactions of the Indiana State Medical Society, at its Eighth Annual Ses- 

sion, held in the City of Indianapolis, May 19, 1857. 8vo. pp. 74. 

2. The Transactions of the New Hampshire Medical Society [Sixty- Seventh An- 

niversary), held at Concord, June 2 and 3, 1857. 8vo. pp. 104. 

3. Transactions of the South Carolina Medical Association, at the Extra Meet- 

ing in Sumter, July 9, 1856, and at the Annual Meeting in Charleston, Feb- 
ruary 4, 1857. 8vo. pp. 64. 

4. Transactions of the Second Session of the Medical Society of California, con- 

vened at Sacramento, February 11, 1857. 8vo. pp. 43. 

1. The first report comprised in the Transactions of the State Medical So- 
ciety of Indiana, at its session of 1857 is on " the Practice of Medicine," by 
Dr. T. J. Cogley. 

This report is published only in part; enough of it being given, according 
to a note appended to it by the committee of publication, "to show its most 
prominent characteristics." Now, if the entire report was of that excellent 
character it is pronounced by the latter committee, they have surely acted 
unjustly, as well to its author as to those for whose instruction it was pre- 
pared, in omitting any portion of it. It should have been published entire, or 
omitted altogether. 

We are not however inclined, so far, at least, as we are able to judge of the 
character of it from the fragment in the transactions before us, to accord to the 
report of Dr. Cogley the high praise bestowed upon it by the committee of pub- 
lication of the society. It contains, it is true, many judicious remarks and 
correct sentiments, but the account it presents of the actual condition of the 
practice of medicine, in reference to the few diseases of which it treats, is much 
too loose, general, and indefinite to afford much useful information to those to 
whom it is addressed. As an example of this, we may refer to the remarks of 
the reporter on the treatment of pneumonitis. 

Dr. Cogley concludes his report with some general remarks on " the curative 
resources of Nature." 

" One of the first surgeons of London, Mr. Skey, says," remarks the reporter, 
" 1 1 am persuaded that, in proportion as we study disease, and make ourselves 
familiar with the curative resources of Nature, the greater will be our faith 
in her power of reparation, and in her desire to exercise it.' Men adopt dif- 
ferent views of the power of the curative art. With some it holds the relation 
of a vicegerent ; with others, of a handmaid. Our minds are not universally 
impressed with the conviction that Nature cures diseases, and not we ; and that 
the province of the surgeon or physician, beyond which he cannot step one 
foot, consists in removing obstacles in her path. If this wholesome fact were 
impressed more deeply on the professional mind, would it not instinctively 
lead to a closer observation, and, of necessity, to a higher appreciation of her 
powers?" 

That, in the larger number of instances when any organ or tissue becomes 
the seat of an acute lesion, its tendency is to return sooner or later to its nor- 
mal condition and functions there can be no doubt. It is questionable, how- 
ever, whether it is safe to trust entirely to this tendency. Between the plan of 
taking into the physician's own hands the entire management of every disease, 
and "turning nature out of doors," as uncertain and inefficient, if not mischiev- 
ous in her curative efforts, and, on the other hand, trusting to her entirely for 
the cure of disease, there is a medium course to be pursued — neither entirely 



200 



Bibliographical Notices. 



[Jan. 



disregarding the curative powers of Nature, nor relying on them alone — but 
interfering just so far as is necessary properly to direct those powers to the 
production of the desired result; to aid them in their efforts to accomplish it, 
and to remove from them all obstacles to their prompt and successful action. 
And the skill of the physician is mainly exhibited in determining and pursu- 
ing this proper medium in the management of disease — neither interfering too 
much nor too little by the administration of active remedial agents. 

The next report is on the "diseases of the eye and ear," by Dr. T. Parvin. 
After a sensible exposition of the importance of a careful study of these dis- 
eases — their nature, causes, diagnosis and treatment, and the necessity of pro- 
vision being made, for a more full course of instruction in reference to ophthal- 
mic and aural medicine and surgery, in our medical colleges, the report gives 
a concise but interesting sketch of the recent improvements in these especial 
branches. 

The succeeding report is on " fractures and false joints," by Dr. Daniel 
Meeker. The subject of fractures, however, is alone embraced in the portion 
of the report before us ; Dr. Meeker promising to complete the report at a fu- 
ture period. 

So far as it goes, the report is a very sensible and instructive one. In its 
exposition of the improved methods of treating fractures it is perhaps somewhat 
too concise ; it will nevertheless be read with interest and profit. 

A report on the medicinal properties of "Veratrum Viride," by Dr. P. H. 
Jameson, is the one next in order. 

In pneumonia, Dr. J. pronounces the veratrum to be an agent of great power 
and utility. He has often seen it quiet the heart and change the quality of the 
circulation — reducing the local inflammation, increasing the expectoration, and 
indirectly restoring the depurating functions of the liver, in a marked degree, 
without loss of blood, nausea, or salivation. It may be given, in different 
cases, he remarks, either after bloodletting, or along with quinine. For an 
adult he recommends the following formula. One fluidounce of Norwood's 
tinct. of veratrum viride, combined with one drachm nitrate of potassa and one 
ounce of water. A teaspoonful to be given every four hours, alternated, if 
deemed advisable, with small doses of mercury. 

"This treatment alone," Dr. J. remarks, "continued for twelve or eighteen 
hours, in pneumonia, I have seen produce the most satisfactory results — the 
patient's condition being very similar to that observed, in such cases, after a 
copious bloodletting. The pulse will be softened, and have come down from a 
hundred, or a hundred and ten, to seventy or eighty, and this, in many cases, 
without nausea. If the remedy fails, the dose may be increased gradually till 
it is nearly doubled ; this is seldom necessary. It is wrong and hazardous, I 
think, to force the pulse down at once by full doses, and needless to reduce it 
below what, in a given case, may be considered a normal standard, as to fre- 
quency. A greater reduction than this must in some degree interfere with the 
due performance of the functions of the system generally; and to cause it, is 
to tamper with a remedy whose power may not be fully understood. After 
the first twenty-four or forty-eight hours, the dose may be diminished one- 
third, one-half, or even more, unless the pulse should rise, and the symptoms 
grow worse ; such being the case, the dose should be increased." 

Dr. Jameson speaks of the veratrum as a good remedy also in many cases of 
typhoid fever, especially where there is a dry, hot skin, parched, dark brown 
tongue, and a quick, sharp pulse, with sleeplessness. 

" Six drops, he says, may be given every four hours, combined with nit. pot., 
and if there is irritability of the stomach or bowels, a little morphia may be 
added. If the pulse is not reduced in twenty-four hours, the dose may be in- 
creased. When the pulse is as low as seventy, in the adult, I do not attempt 
a further reduction. Under this treatment the skin becomes moist and 
cool, the urinary secretion increased, and the tongue is less dry ; indeed, all 
the symptoms of the disease are mitigated, and in some cases, I have no doubt, 
the duration of the fever is shortened. It is but fair to add, that in both ty- 
phoid fever and pneumonia I have sometimes, though rarely, administered 
verat. vir. so as to produce nausea, without the least impression upon the cir- 



1858.] 



Transactions of State Medical Societies. 



201 



dilation, and consequently with no benefit to the patient. The remedy is 
valuable, not only in such cases of typhoid fever as before referred to, but in 
all cases where the pulse rises above one hundred, whether attended with rest- 
lessness or stupor.-" 

Dr. Jameson has employed the veratrum in two cases of puerperal fever, with 
what he considered favourable results. 

"A very rapid pulse," Dr. J. remarks, "is characteristic of puerperal fever; 
it is generally small, because the great current of blood is diverted from its 
natural channel, and thrown on to the weakened and congested capillaries of 
the inflamed peritoneum. These vessels cannot unload themselves until the 
heart's action is reduced. To accomplish this end, Dr. Gordon of the last cen- 
tury, Dr. Robert Lee, the younger Baudelocque, Dr. Meigs, and many others, 
advise us to bleed early and freely, and repeat as often as the pulse rises. How- 
ever scientific this treatment may be, I believe it does not meet with the gene- 
ral approval of Western physicians. Bleeding modifies the character of the 
blood by lessening its vitality, which in this locality is not always desirable. 
With the verat. vir. the pulse can be as much reduced in frequency and kept 
down as long as the practitioner desires. With it puerperal fever may be, if 
not arrested at its outset, modified in its course, and effusion, that most fatal 
of its consequences, in many cases, prevented." 

In regard to the safety of the veratrum as a remedial agent, considering the 
powerful influence it exerts over the action of the heart, the question is briefly 
considered by Dr. Jameson. 

"Sometimes, though very rarely," he remarks, "verat. vir. produces nausea 
and vomiting, with great depression; but I have seen worse effects, and harder 
to correct, from antimony. There are sometimes sensations of choking or 
smothering, and difficulty in breathing; or there maybe hiccough or dizziness, 
all of which soon pass away when the use of the remedy is suspended. Like 
mercury, antimony, opium, quinine, or chloroform, verat. vir. is not only power- 
ful for good, but doubtless, in unskilful hands, sometimes potent for evil. That 
which can do no harm seldom does any good." 

To the report of Dr. Jameson succeeds the history of a most interesting case 
of amputation at the shoulder-joint, by Dr. Calvin West. 

The operation was performed on a lad eight years of age, who had recently 
suffered an extensive and serious injury of the entire arm of the right side, 
destruction of the deltoid and coroco-brachialis muscles, fracture of the humerus, 
close to, and extending, under the attachments of the capsular ligaments, into 
the shoulder-joint, and destruction of portions of the pectoralis muscles. On 
the thirtieth day after the accident, cicatrization was complete, and the patient 
discharged cured. 

The two reports which follow, the one on bloodletting in pneumonia, and the 
other on purgatives in dysentery, give each, on the question embraced by it, 
simply the opinion of a single practitioner, which opinion is neither given with 
all the necessary details, nor with a clearness and definitiveness to render it 
of value as a guide for the practice of others. 

The next report, " on medical education," by Dr. Chas. Fishback, contains 
much in relation to this most important subject, that is at once pertinent, judi- 
cious, and practical. We confess that we are not particularly pleased with his 
scheme of a free college, and a course of lectures to be continued through three 
consecutive years. 

To the foregoing report succeeds a biographical sketch of Dr. Elizur Deming, 
by Dr. J. S. Bobbs. 

The Transactions of 1857 close with the address of the President of the So- 
ciety, Dr. Daniel Meeker. We had marked as particularly deserving of notice 
many paragraphs of this very sensible discourse, but must confine ourselves to 
that portion of the address which embodies the remarks of Dr. M. on the sub- 
ject of the legal protection of the medical profession by legislative enactments. 
We present these remarks without comment. 

" When," says Dr. M., " the popular mind is legitimately and well informed, 
whatever may be the opinions or wishes of the profession, I doubt not but the 
legislature will enact positive laws — protection not merely to the profession, 
but to the people." " When the people understand that their own interests in 



202 



Bibliographical Notices. 



[Jan. 



such enactments far transcend all that can accrue to the profession, surely 
their aversion to protective means should cease." " We have no doubt that 
judicious legal enactments regulating the practice of medicine in this State 
would result in general good to the people as well as to the profession — requiring 
some fixed standard of qualification for all those who practise the healing art." 
" Should the time arrive when efficient laws are enacted for the encouragement 
of the science of medicine, it will be through preliminary culture of the public 
mind by the agency of medical men. The people are more ignorant of the 
principles of medical science than they are of those of the other learned sci- 
ences." " The public ministrations of the clergyman are laid open for the ap- 
preciation of all. The majority of his congregation are competent judges of 
his pulpit efforts. Yet he is not allowed to act in this capacity until he has 
been examined and licensed by a competent board of officers of the church, 
appointed for that purpose. The lawyer is brought to a still severer test ; all 
his legal papers must be drawn up with the most scrupulous technical accuracy, 
or disgraceful defeat and pecuniary loss is the result. Here all the great errors 
committed are open and apparent, involving the reputation and standing of the 
practitioner. He is brought into conflict with his opponent, before a sagacious 
court that fully understands all the principles discussed, and that instructs in 
its decrees which party is correct. The knowledge and abilities of the physi- 
cian are not tested in the same open and direct manner. The character of his 
business is such as to more or less conceal it from public gaze. His dealings 
are with the secret and hidden things of life. He does not come in contact 
with any opponent, his labours are not watched and decided upon by the same 
sagacious tribunal. The grave may too often conceal his blunders ; few around 
are competent to decide whether the protracted sufferings, the lost vigour, and 
the shattered constitutions of those who survive are the necessary consequences 
of disease, which could not have been prevented, or the result of inefficient or 
injurious treatment. Indeed, so erroneous is the judgment of those around 
him, that he is often praised for his errors and censured for his highest skill. 
He sees the bold and unscrupulous pretender, ignorant alike of the diseases he 
treats and the remedies he employs, exalted in public opinion for recoveries of 
which the least can be said is, that his bad management did not effectually 
prevent." 

2. The Transactions of the sixty-seventh anniversary of the New Hampshire 
Medical Society open with the Address of the President, Dr. Francis P. Fitch. 
The subject of the address is a most important one — the want, namely, of sani- 
tary knowledge. 

That the health of a community has " a large and direct influence not only 
on the happiness, but also on the wealth of the people who compose it," is a 
truth which no one, who has examined the subject with the slightest degree of 
attention, will be prepared to controvert. That the health of a community 
may be materially improved, and the value of life in its midst considerably 
augmented, is likewise a truth, which has been fully established by the result 
of the judicious sanitary measures that have been carried into effect, of late 
years, in many of the cities and towns of Great Britain. 

We may, without the slightest exaggeration, adopt the language of Lemuel 
Shattuck, Esq., in the report of the sanitary commission of Massachusetts, 
"that in every year in this commonwealth," and the remark may be extended 
to every other commonwealth throughout the land, "thousands of lives are lost 
which might have been saved ; that tens of thousands of cases of sickness occur 
which might have been prevented ; that a vast amount of unnecessarily im- 
paired health and physical debility exists among those not actually confined by 
sickness; that these preventable evils require an enormous expenditure and 
loss of money, and impose upon the people unnumbered and immeasurable 
calamities, pecuniary, social, physical, mental, and moral, which might be 
avoided, and that means exist within our reach for their mitigation or removal; 
and that measures for the prevention will effect infinitely more than remedies 
for the cure of disease." And these views of the immense unnecessary waste 
of physical energy and of life from ignorance and carelessness, are fully con- 
firmed by the highest authorities in England. In some valuable " conclusions 



1858.] 



Transactions of State Medical Societies. 



203 



and suggestions," appended to an elaborate report on " diseases and compara- 
tive rates of mortality/' the British General Board of Health express most 
emphatically a firm conviction " that half the attainable period of human life 
is lost to all who are born." 

But to avoid disease, to promote health and physical vigour, and prolong 
life amid a community, we must know what are the causes in each which tend 
to depress the physical vigour, impair the health, induce disease, and shorten 
the lives of its people ; we must be put in possession of those facts upon which 
alone useful practical sanitary knowledge can be based. These facts comprise 
those derived from, 1st, a careful survey of the medical topography of every sec- 
tion of the State ; 2dly, an intimate acquaintance with the personal and domestic 
habits and condition of the inhabitants, their occupations, and ordinary food ; 
the location, condition, construction, and domestic economy of their dwellings, 
and the density of the population ; 3dly, suitable enactments for securing, by 
adequate sanctions, the full and accurate registration of births, marriages, and 
deaths throughout the commonwealth, and the preparation and stated publica- 
tion, at proper intervals, of a well digested and classified abstract of such 
registration. 

We quote the concluding remarks of Dr. F. in the address before us, and 
earnestly press them upon the attention of every physician throughout the 
length and breadth of the land. 

"The subject before us has increased in magnitude and consequence with 
every hour devoted to its consideration, and you will pardon the earnestness of 
my convictions if I may seem to have overstated its importance. Habits of 
thought, forced upon us by daily duties and anxieties, and confirmed by the 
prevailing tone of public sentiment, very naturally incline us to the conclusion 
that the appropriate, if not the exclusive sphere of the physician, is the cure' of 
disease. But is that a complete or satisfactory definition of the purposes of our 
high vocation ? Placed by our studies and pursuits upon a vantage ground 
from whence we discern dangers, imperilling health and life, which are un- 
known to others, shall we not prove false to the obligations we have assumed 
if we neglect to point out these dangers, and to show, as we may, how they can 
be averted? Here is presented an open and inviting field for the exercise of 
that active and enlarged spirit of benevolence and philanthropy which should 
everywhere characterize and adorn the votaries of medicine ; and if we would 
in our day accomplish anything great or noble, in what way can it be so surely 
effected as in thus labouring for the improvement of our race?" 

The first of the professional reports is that on Surgery, by Dr. George H. 
Hubbard. 

The first subject noticed by Dr. H. is that of injuries of the head. 

"Formerly/ 7 says Dr. H., "when an injury w*as inflicted upon the head, the 
first thing to be done was to bleed the patient, without stopping to inquire 
whether there was concussion, compression, or neither; and there can be no 
doubt that many lives have been sacrificed to a blind submission to this popular 
demand for bloodletting. We have learned, however, that the cases are few 
which demand bloodletting at all, and very few indeed which require it imme- 
diately after the injury. 

Five interesting cases of the successful treatment of ununited fractures are 
related by Dr. H. The first of these occurred in a lad twenty-two years of 
age, the fracture being of both bones of the leg. It was managed simply by 
appropriate splints and perfect rest. Complete union occurred at the end of 
four week&. The second was in a male, twenty-four years of age ; the fracture 
being of the humerus. The operation of resection was performed, and the ends 
of the bone were then fastened together with gold wire, and the limb inclosed 
in a gutta percha splint, fitted to it previous to the operation, and encircling 
three-fourths of the arm, so as to leave space to dress the wound without dis- 
turbing it. At the end of three months, union was perfect. The third case 
occurred in a female, thirty-five years of age. The fracture was of both bones 
of the leg. It was managed by putting the limb in a gutta percha splint, and 
directing the patient to walk about the house with a cane, bearing as much 
weight as she could on the affected leg. In a week, she complained of pain 



204 



Bibliographical Notices. 



[Jan. 



and throbbing at the place of fracture. She was then directed to keep quiet 
in bed. In four weeks there was no motion at the fracture, and in due time 
the cure was perfected. The fourth case was in a male, age not given. The 
fracture was of the femur. Five months subsequent to the accident, there was 
evidently no ossific union, and the limb was shortened an inch and a half. 
" An attempt was made to break up the ligamentous union and bring the limb 
to its proper length, and then perform Brainard's operation, and thus effect a 
cure. The limb was accordingly dressed as for recent fracture, and extension 
attempted. As much power was applied as the patient could bear, and con- 
tinued forty-eight hours. At this time there was no appreciable lengthening 
of the limb, but great pain, throbbing, and soreness were the result of the ex- 
tension. This plan was abandoned, and, to take advantage of the inflammation 
thus excited, the starch bandage was applied and the patient kept quiet in bed 
a few weeks, and then on crutches a few weeks, the limb in the mean time get- 
ting more and more strength, so that at the end of three months she could walk 
with a cane, and is now perfectly cured, except the shortening of the leg/' 
The fifth case was in a female twenty-five years of age. The fracture was of 
the humerus. Four months after the accident there was no union, but very 
free motion. Dr. Brainard's operation was performed Nov. 21, 1856, and re- 
peated at the end of twelve days. In four weeks union was complete. 

"The method of reducing dislocations of the hip-joint by manipulation," Dr. 
H. remarks, "long ago taught by Professor Nathan Smith, and lately brought 
prominently to public notice by Dr. Reid, of Rochester, N. Y., is becoming 
firmly fixed in the favour of the profession. Cases are continually being re- 
ported of its successful application. Discussion has fully proved that numerous 
surgeons, who were students of Dr. Smith, have been for many years in the 
habit of reducing dislocations in this manner, as they were taught by that dis- 
tinguished surgeon. And reflection upon the philosophy of this method is 
having a great influence upon the reduction of dislocations of other joints. We 
are learning that but a small amount of force is necessary to reduce luxations, 
if conjoined with an intelligent manipulation properly directed to relax those 
muscles which are put on the stretch by the displacement of the head of the 
bone. New ideas and principles are daily developed, and we may safely say 
that, on this point, surgery is making improvement. 

The reporter adduces the following case to illustrate what Nature will accom- 
plish in extensive injuries of a limb, when carefully watched and slightly 
aided, as a lesson to the surgeon not to be over-hasty in sacrificing a limb 
that, without danger to the life of the patient, may become more serviceable and 
much better, in all respects, than any artificial substitute. 

" Ellen Ryan, aged thirty years, jumped from a car, which was in motion, at 
the depot. Falling on the platform, she rolled off, and one foot was run over by 
the car wheel. The soft parts of the dorsum of the foot were entirely jammed off, 
the metatarsal bone of the great toe crushed to small pieces, and the remaining 
metatarsal bones separated from the tarsus, but otherwise uninjured. The soft 
parts of the bottom of the foot were uninjured. The great toe and its fractured 
metatarsal bone were removed, preserving as much as possible of the sole of the 
foot. The leg and foot were placed in a carved splint, which kept the foot in 
proper position, and the whole dressed with cold water. Profuse suppuration 
followed, and in about a week it became necessary to remove the second toe. 
By keeping the bones in contact, they became attached or consolidated together. 
The surface healed kindly, the contraction of the large cicatrix drawing the 
sole of the foot up around the edges giving the appearance of an Indian mocca- 
sin. At the end of about nine months, the foot became sound, and she resumed 
her place in the cotton-mill, and is now tending four looms and earning good 
wages. She walks the streets without a cane, and with scarcely a perceptible 
halt in her gait." 

From the several interesting cases appended to this report we select the fol- 
lowing, communicated by Dr. Wm, Laughton: — 

"I was called to a child, seven months old, which had been screaming vio- 
lently; it was then sobbing and restless. The mother stated that it had had 
several such spells. I discovered no particular cause for the condition. I pre- 



1858.] 



Transactions of State Medical Societies. 



205 



scribed turpentine mixture to be followed by an opiate. A day or two after, I 
was called again to the child in the same condition. At this time the mother 
directed my attention to the umbilicus, fearing hernia. On examining the 
abdomen, I discovered a dark speck about one inch above and to the left of the 
navel. It proved to be the open end of a sinus. By using a probe, I felt a hard 
substance about half an inch inside the opening. By a very little cutting upon 
a director, I was enabled to reach the foreign body, which I extracted with a 
pair of fine forceps, and it proved to be a darning-needle. The direction of 
the needle was transverse, and apparently between the fascia and external mus- 
cle. It was corroded and surrounded by pus, was easily extracted, and the child 
at once relieved. How long this needle had been there, or how it got there, 
no one knew. It was probably accidentally pushed in while handling the child, 
and escaped the notice of the mother in dressing. A knowledge of such cases 
should lead to careful examination of infants, especially in cases of convulsions 
or violent screaming." 

A very instructive report on the " nursing sore mouth, its nature, causes, and 
treatment," is presented by Dr. T. T. W. Pray. 

The main object of this able and instructive paper is to show the identity of 
the disease known as the sore mouth of nursing women with aphthae. This 
identity Dr. Pray believes to be established by the following facts : Both dis- 
eases occurring epidemically without any discoverable connection with season 
and temperature; their having the same laws in regard to location — some places 
being entirely free from the occurrence of either ; the similarity of their phy- 
sical lesions, and their both affecting persons of similar constitutions and con- 
ditions of health — those of a lax fibre, thin in flesh, of anaemic appearance and 
scrofulous diathesis. 

After a very full detail of the symptoms and progress of the nursing sore 
mouth, Dr. Pray asks, What is its nature, or what is the disease itself? 

"We answer that, with our present information on this subject, we must 
pronounce nursing sore mouth and aphthae alike. Upon their physical histories 
we cannot affirm them to be different. Their resemblance, both in their rise 
and progress, would tend to show, with no small degree of probability, their 
identity. This identity, however, resting upon this theoretical aspect of the 
case — which seems to us, nevertheless, the just interpretation of all facts known 
relative to this disease — may be held provisionally, until it be tested by future 
investigation as regards the physical lesions of the disease, by which such 
distinctions can be established. 

"We regard the disease as local in its nature, occurring as an epidemic and 
sporadically, just as all epidemic diseases do. It is a frequent complication 
of idiopathic fevers and disordered states of the digestive organs. But the 
reason why vesicles and ulcers should be first seen in the mouth or elsewhere, 
we are unable to explain. The observations of Dr. Hale on this point are not 
inappropriate here. He says : * From the great liability of the stomach to be 
disordered in this complaint, and especially from the fact that those remedies 
only are of permanent benefit which act upon the stomach, it would seem that 
it is chiefly through the intervention of that organ that the disease is produced. 
We know of no direct sympathy between the parts in which this affection first 
appears and the mammae ; while the stomach is very closely connected with 
the mouth and fauces on the one hand, and with the uterus, and all the other 
parts associated with the latter organ on the other.' " 

In regard to the treatment of the nursing sore mouth, Dr. P. remarks, that 
different constitutions require different remedial measures. Tonics may be 
best adapted to one class of subjects, while in another an entirely opposite de- 
scription of medicines are demanded. Scarcely two cases will be found alike, 
hence we can fix upon no general plan of treatment adapted alike, in all its 
details, to every patient. 

" The first thing that should be attended to is the state of the stomach. If 
there be acidity, small doses of magnesia, or bicarbonate of soda, once or twice 
a day, or sometimes the vegetable or mineral acids will serve to correct this state. 
If constipation predominates, some mild laxative, such as a moderate purge of 
calomel and soda, Seidlitz powder, castor* oil, sulphur and cream of tartar, will 
JS T o. LXIX.— Jan. 1858. 14 



206 



Bibliographical Notices. 



[Jan. 



avert this difficulty. A gentle evacuation of the bowels is desirable in the 
earlier stages of this complaint, because it exerts a curative influence over the 
sensitiveness of the ulcerated surface. A prominent point in the treatment is 
to keep the bowels, especially in the commencement of the disease, in a soluble 
condition. But active and irritating purgatives should never be administered, 
on account of the liability of the mucous membrane of the intestinal tube to 
ulceration, and severe diarrhoea. 

" The bowels being cleared, measures should be directed to subdue the feverish 
excitement existing in some patients. Generally there is no difficulty in effect- 
ing this, unless there be some constitutional irritation, occasioned by the exist- 
ence of another disease lurking in the system. There are not many cases where 
venesection would be advantageous ; it might be, indeed, dangerous to practise 
it." "It is far better, in uncomplicated cases, to use other medicines which 
eminently possess the qualities of lowering the pulse and allaying inflammation. 
Sometimes a gentle emetic, especially when the stomach is disordered, will be 
serviceable. For this, ipecac, is far the best. 

" After the feverish state of the system has subsided, or even when there is 
slight exaltation of the pulse, we have given internally the following mixture, 
This has been used successfully for the last nine years, both in aphthae and 
nursing sore mouth, and with like results; its virtues, doubtless, lie in its tonic 
qualities : Myrrh, gij ; carb. potass., gr. xxx ; aq. rosae, 3 iij ; sulph. ferri, ^iss ; 
spts. lavend. comp., ^vss; sacch., ; mix and compound in the same manner 
as the mist, ferri compos, of the U. S. Pharmacopoeia." " We have given a tea- 
spoonful of this three times a day, and at the same time used a wash of sul- 
phate of zinc, six to eight grains to an ounce of water, for the mouth. If the 
physician is called early in the disease, there is no compound more serviceable." 
"In the more feeble subjects, other tonics are of importance. There are in- 
stances, after the acme of the inflammation is passed, where quinine seems to 
stay the progress of the ulceration, and render the mother able to nurse the 
child. Here we would remark that almost every tonic is beneficial. Quassia, 
iron in some of its preparations, iodide of potassium, arsenic (?), manganese, 
etc., have been used with success. When the mouth is largely involved, care 
should be had that all medicines be as palatable as possible, free from all irri- 
tating properties. It is desirable that they be prepared without the use of 
alcohol. 

" Local applications have not unfrequently but a feeble power over the ulcera- 
tion. Sometimes they seem to exert palliative influence, and occasionally pro- 
duce permanent good. They are usually conjoined with medicines directed to 
the stomach. Those generally employed are nitrate of silver, sulphate of zinc, 
tannin, decoction of logwood, etc." 

For the diarrhoea, the food should be unirritating from the onset. "When 
the evacuations are green, or of a sour smell, magnesia, or a mixture of this 
with rhubarb, may be administered ; or pure castor oil, with some astringent, 
may be substituted. Prepared chalk, fluid magnesia, some of the vegetable 
astringents — such as kino, catechu, rhatany, or tannic acid — can be taken with 
profit. We have seen the use of creasote, six to ten drops to four ounces of 
water, check the discharges when everything else failed. Friction over the 
abdomen, flannel rollers about the body, rubefacients, especially if there is 
pain, anodyne enemata, and warm clothing, are highly important adjuvants." 

" There are some cases of the disease which seemingly reject all treatment. 
The physician is called too late to check the progress of ulceration and the 
exhaustive diarrhoea, or else there is some other complication which thwarts 
all the appliances used to arrest the disease. To continue nursing will keep 
up a constant irritation in the system. Weaning the child will almost always 
cure the mother if seasonably undertaken. But there are instances where re- 
sort to this is inconvenient, to say the least. In such instances we must balance 
the risk taken, and in a good constitution nursing may be long continued. But 
where there are any indications of exhaustion, or an anaemic state of the sys- 
tem, a regard to the health of the mother should be paramount, and she should 
give up nursing at all hazards. Even then, it will be difficult sometimes to save 
life. In a majority of cases, however, there is no such danger, and, although 



1858.] Transactions of State Medical Societies. 207 



weaning is admissible when circumstances admit it, it is not indispensable, 
and women worry through after much exhaustion and suffering, and after all 
is over their health does not seem to be permanently injured thereby. As a 
general rule, nursing should never be persisted in, when remedies are ineffica- 
cious to stop the course of the disease. The length of time which one must 
wait to test the inefficiency of remedies must of course vary according to the 
urgency of the symptoms." 

" When the condition of the patient will permit, the diet should be mild, 
generous, and of easy digestion ; such as a good supply of fresh, tender, animal 
food, milk, milk-porridge, rice, eggs, and good vegetables. Ale and porter will 
assist digestion, and their use cannot be well dispensed with. Sometimes 
broths and soups do not disturb the healthy operations of the stomach. Food 
of an undigestible nature should never be prescribed, as it will produce only 
evil." 

In regard to preventive measures, let the female, says Dr. P., " exercise fre- 
quently in open air. Keep her bowels in a soluble condition. Let her food 
be simple and nutritious. Employ her mind upon subjects that will interest, 
rather than upon the annoyances of gestation, and, in fine, let there be a free 
use of everything which can amuse and make the patient cheerful. 

" To recapitulate : From the discussion of this subject, we arrive at the fol- 
lowing conclusions: — 

" 1st. Nursing sore mouth is not a nova pestis. 

"2d. It is not indigenous to this country. 

" 3d. It is often of an epidemic character, and therefore governed by the same 
laws as govern other epidemical diseases. 

44 4th. It is not anaemia, nor is it occasioned by the loss of a particular prin- 
ciple of the blood ; nor can it be scorbutus, but most probably the disease in 
question is aphthae of a severe and obstinate form." 

The report cn practical medicine, by Dr. W. W. Brown, contains a brief 
sketch of the principal epidemical diseases prevalent in the city of Manchester, 
from the year 1853 to 1857 inclusive. 

The diseases noticed are, cholera infantum, malignant cholera, dysentery, 
typhoid fever, scarlatina, pleurisy, and pneumonia. 

The report contains much that is interesting, but nothing that can be re- 
garded as particularly novel. On the subject of venesection in pleurisy and 
pneumonia, in regard to which some very heterodox opinions appear to be 
prevalent among the practitioners in different parts of the United States, Dr. 
Brown holds the following decided language : — 

" During the past winter, pleurisy and pneumonia have prevailed to a greater 
extent than is usual here, and we are sorry to be obliged to acknowledge the 
fact, that many of our physicians are now, from some cause, too timid or too 
cautious in the use of the lancet. One of our regular physicians was heard to 
remark recently, that he had not bled a person for six years ! He was asked 
how he cured pleurisy and pneumonia? With Dover's powder and tincture 
of aconite, was his reply." " The argument is, that diseases have changed, and 
require a milder treatment than formerly ; but the argument, cceteris paribus, 
is without foundation. It is evident that a person of a robust constitution re- 
quires depletion as much in these days, while labouring under acute inflamma- 
tion, as he would have twenty years ago. And furthermore, we are constrained 
to say that, in our belief, many persons die annually in the city of Manchester, 
of acute inflammatory diseases, treated by various quacks, or in a feeble, in- 
adequate mode by some of our regular physicians, that might be cured by pro- 
per, energetic, and decided treatment. If the people choose to be led astray 
by the multifarious varieties of empiricism of the present day, let it never be 
said that we are forsaking the accumulated light of science, made brighter and 
brighter by the addition of the labours and experience of all the illustrious 
sages of our profession, from the days of Hippocrates to the present time. The 
time will come, if not in our day, when the medical profession will have less of 
charlatanism connected with it than at present, for ' truth is powerful and will 
prevail/ " 

The subject of an oration delivered before the New Hampshire Medical 



208 Bibliographical Notices. [Jan. 

Society on the first day of the session, the transactions of which are under con- 
sideration, by Dr. Thomas H. Marshall, is " the contributions of quackery to 
true medical science." We like the general tone of this oration. We freely 
admit with its author, that, to the truly scientific physician, "all means are 
his." " His is the search for truth, and he will not refuse the boon by what- 
ever hand it may be offered. But in doing so, he takes nothing on trust. 
' Prove all things, hold fast that which is good/ is his motto. His facts must 
not be seeming, but fixed facts, and his conclusions will be based, not upon one, 
or a few of those, but upon many, carefully collated and rigidly analyzed." We 
are not disposed to deny that some few useful remedies, an occasional happy 
formula have been introduced or made conspicuous even by empirical pre- 
tenders ; and we have no objection to receiving these or any other really valua- 
ble hints that may be offered us by outsiders. We agree with the late Dr. 
Wistar, that " if an ignorant nurse should happen, in the course of long years 
of practice, to stumble upon something that may be advantageously employed 
for increasing the comfort or assuaging the suffering of a patient, it would be 
folly in us to reject it, because of the humble source through which it reaches 
us." But we should not feel disposed to dignify what means or hints we thus 
derive as contributions made by ignorance or quackery to true medical science. 
Dr. Marshall speaks of valuable "modes of practice" as having been introduced 
or rendered conspicuous by empirical pretenders. Of these we must plead our 
entire ignorance ; we are not aware of any valuable plan for the treatment of 
disease, the parentage of which can be fairly traced to such a source. 

While we freely admit that positive as well as negative good has accrued to 
legitimate medicine from the very ignorance and recklessness of quackery, we 
nevertheless insist that Dr. Marshall has conceded far more credit to certain of 
the quackish practitioners of the day for the benefits they have indirectly con- 
ferred on true medical science, than they justly deserve. 

We are not prepared to credit quackery with the slightest contribution made 
to legitimate medicine. If, perchance, from its blind ministrations some useful 
hint may be derived, developed, and properly applied by the scientific physician, 
good and well ; but as the boon thus conferred cannot be received as the legi- 
timate fruit of quackery, let us not be over anxious to watch its empirical 
practice as one of the sources through which sound therapeutics is to be bene- 
fited and advanced. 

In a report on the diseases of Strafford District, Dr. Levi G. Hill notices the 
unusual number of cases of puerperal convulsions that occurred during the 
year 1856, and the fact that, after parturition, recovery was not as favourable 
as usual. 

Of puerperal convulsions he relates the history of nine cases. Three of these 
terminated fatally. The convulsions occurred at different periods before, during, 
and subsequent to parturition, principally in young subjects. In all the cases 
bleeding and purgatives were employed, and in most of them chloroform and 
ether by inhalation. 

" If we inquire," says Dr. Hill, " into the philosophy of these cases, we shall 
see the importance of unloading, so to speak, the womb, bowels, and blood- 
vessels, as soon after the convulsions occur, as prudence will permit, if indeed 
we do not anticipate and prevent them by suitable evacuations." 

An interesting article, containing miscellaneous observations in obstetrics 
and diseases of women, is communicated by Dr. Wm. Henry Thayer. 

In an inquiry into the effect upon the duration of labor produced by artificial 
rupture of the foetal membranes, Dr. T. arrives at the conclusion that a rup- 
turing of the membranes on the part of the practitioner is rarely called for, 
either after or before complete dilatation of the os uteri. When the membranes 
are so exceedingly tough as to delay the labor, as we may judge to be the case, 
when with a large pelvis, a full dilatation of the os uteri, and regular and suffi- 
ciently active pains, they remain unbroken, there can be no doubt as to the 
propriety of their artificial rupture. Where, also, the labor is impeded by the 
large amount of liquor amnii, or where there is a large quantity of fluid between 
the amnion and chorion, the artificial rupture of the membranes will tend to 
expedite delivery. 



1858.] 



Transactions of State Medical Societies. 



209 



To guard against flooding, Dr. T. recommends the administration of ergot 
immediately after the termination of every case of labor, and we consider the 
recommendation a safe and judicious one. 

Dr. T. does not believe it to be necessary to wait until pulsation in the cord 
has ceased before applying the ligature, and dividing it. From a careful con- 
sideration of the subject, he concludes, that if respiration be fully established 
in the newborn infant, the cord may be cut, whether pulsation has ceased or 
not in the cord. We fully agree with him as to the correctness of this con- 
clusion. 

" There are cases," he properly remarks, " in which the establishment of 
respiration appears to be actually prevented by too full a state of the vessels, 
and the child would perhaps never breathe if the umbilical cord were not 
divided." 

Dr. T. relates a case of conglutination of the os uteri, the result apparently 
of extensive and long continued ulceration of the cervix uteri, in which delivery 
took place after the incision of the cervix. 

3. In the minutes of the extra meeting of the South Carolina Medical Asso- 
ciation we meet with some interesting remarks on the employment of chloro- 
form. Dr. Mayes has seen prompt relief produced in colic, and similar affec- 
tions from a few drops of a solution of camphor (one drachm) in chloroform 
(one fluidrachm). As a local application in neuralgia, Dr. J. B. Witherspoon 
highly recommends the following: R. — Camph., sulph. morphise, aa, 3j ; chlo- 
roform ^j ; lard §ss. — M. Dr. A. N. Talley has given the chloroform by inha- 
lation in lead colic with good effect, using at intervals, as a local application, 
an ointment composed of chloroform ^ij ; oxyd. zinci gss : cerat. simpl. ^j. — M. 

In the address, at the opening of the annual session by the president, Dr. 
Horlbeck, it is very justly remarked, as one of the impediments to the success 
of medical associations, that "we are too apt, in the inception of an under- 
taking, to expect extraordinary results to arise at once from it, and when we 
are disappointed at the non-fulfilment of overwrought anticipations, to sink to 
a proportionate state of depression." 

Unfortunately, too many of those who enter into our medical associations, in 
full confidence that every desired reform in the condition of our profession is 
to be promptly effected through their agency, overlook, or at least greatly un- 
derrate the silent but not less beneficial influence these associations constantly 
exercise, and not experiencing through their action, at once, results commen- 
surate with their exaggerated anticipations, whether in reference to what they 
esteem the chief good of the medical profession, or in the promotion of their 
own individual interests, they permit their zealous co-operation as members 
gradually to flag, and finally to become extinguished. 

Well conducted and zealously supported medical associations, independently 
of their agency in the accumulation, collation and arrangement of facts, adapted 
to improve and extend the science and the practice of medicine, are promotive of 
influences that are not less beneficial to the true interests of the members of 
the profession, individually and collectively. 

In the appendix to these Transactions, is contained a paper read at one of the 
sessions of the society, by Dr. J. A. Mayes, presenting observations on the 
medical properties of the gelsiminum semper vir ens, or yellow jessamine. The 
following concluding paragraphs exhibit a summary of Dr. Mayes' opinion of 
the remedial properties of the gelsiminum drawn from actual observation of 
its effects. 

" I regard it as a direct sedative; more safe and manageable than veratrum 
viride, and more generally applicable in practice. 

" I esteem it a most valuaole adjuvant to other treatment in all cases where 
high arterial excitement exists, in which it is desirable to lessen the frequency 
of the pulse and to calm excitement, and where, as in the case of injuries, it is 
desirable to lessen the irritability of the nervous system ; also, in that trouble- 
some hysterical exaltation of the nervous sensibilities, so often met with in 
enervated females, its value cannot be too highly estimated. 

" In short, it is a specific for no particular disease, but an admirable adju- 
vant in the treatment of nearly all. 



210 



Bibliographical Notices. 



[Jan. 



"With its poisonous effects when given in overdoses, I have no acquaintance, 
hut do not doubt the possibility of its doing harm in the hands of the care- 
less." 

In a paper by Dr. Ware, on the use of mercury in typhoid fever, we find a 
very pointed protest against the employment of this, with many, universal fe- 
brifuge, in that disease. The doctor founds his opposition upon the essential 
difference there exists between the pathological character of typhoid fever and 
those affections in which mercurials manifest their happiest effects, and upon 
the efficacy of remedies of a totally different character, namely, stimulants and 
anodynes. 

It is unquestionably true that from mercurialization there is no disease in 
which, as a general rule, less benefit is to be anticipated than in typhoid fever, 
and yet in the early stage of this fever, and in certain of its complications 
where a loaded condition of the bowels is manifest, mercury constitutes one of 
our best and safest purgatives ; under certain circumstances, even when admi- 
nistered so as to produce a gentle alterative impression, it will be found de- 
cidedly beneficial. 

The oration delivered by Dr. Smith at the annual session presents, in clear, 
forcible, and manly language, a general sketch of the objects and efficiency of 
medical organization, and an urgent appeal to the physicians of the state to 
unite in their furtherance and support. 

4. The physicians scattered abroad in California deserve credit for the early 
efforts made by them to effect an organization, so as to " bring together, from 
every section of the State, the regular members of the profession ; to harmonize 
their views ; to elicit reports on the character and treatment of the various dis- 
eases appertaining to the State; to encourage habits of careful observation and 
patient research, and thus to elevate the moral and scientific grade of the pro- 
fession individually and collectively/' The Transactions of the two annual 
sessions that have been held of the California State Society evince a degree of 
zeal and industry that was scarcely to have been expected when we take into 
consideration the condition of the population amid which the physicians who 
have gone there are located, and the adverse circumstances by which, in the 
early period of their immigration, many of them were necessarily surrounded. 
The results of organization, have, we are assured, 1 been already realized among 
the physicians of California, by the infusion into their ranks of a proper spirit 
of emulation; by the establishment of the most useful and friendly relations 
between the members of the profession throughout every portion of the State, 
and the inauguration of a system of extended observation and research, which 
cannot fail in due time to redound to the advancement of science. 

The subject of the annual address by Dr. E. S. Cooper, of San Francisco, is 
" deformities of the locomotive apparatus/' or, more properly, the description 
of an apparatus by which patients labouring under chronic deformities of the 
lower extremities are enabled to walk about during their treatment. 

" I do not claim/' Dr. C. remarks, " that the series of apparatus which I have 
invented will remove all difficulties and secure a complete exemption from fail- 
ure in attempts to effect an entire cure of all cases ; but I do claim that they 
simplify the treatment, and can be made to succeed in cases when failure must 
be unavoidable by any other process heretofore brought into general use among 
the profession, and I claim that they do so by possessing at least the following 
superior merits: — 

"1st. In distributing the pressure nearly equally over the entire surface of 
the deformed limb, and thereby obviating the danger of sloughing, as well as 
lessening, to a very great extent, the attendant pain produced by the use of all 
ordinary apparatus. 

"2d. By being so simple in their construction as to be readily applied by 
any practitioner of ordinary ingenuity. 

" 3d. Being nearly like the ordinary boots, which all experience proves to 
be better adapted to walking than any other ; the ultimatum of our treatment 



i Report of the Corresponding Secretary, Dr. T. M. Logan. 



1858.] Transactions of State Medical Societies. 211 

being to bring the foot as nearly as possible into proper condition to bear with 
grace and ease the boot or shoe of everyday use. 

" 4th. By rendering walking the great agent of cure ; being so arranged that 
many steps the patient takes places the contracted tissue in a state of increased 
tension, let the deformity be of what variety it may. 

" 5th. In the great ease and comparative comfort with which they are worn, 
and by which patients are rendered more persevering in their use. This is, of 
itself, a desideratum, because in all very obstinate cases the orthopedic surgeon 
has sufficient need of the greatest perseverance on the part of the patient. 

" In fact, there are many cases susceptible of complete cure, and cause little 
inconvenience by the use of apparatus, which keeps up slight but regular pres- 
sure for two or three years, allowing the patient in the mean time to go about 
as usual, in which any attempts to effect an immediate change in the parts, 
either by knife or apparatus, would jeopardize the patient's life." 

The apparatus of Dr. C. is thus described : — 

" The spring boot is very like an ordinary boot, made on a last, two or three 
sizes larger than the foot. The boot is open in front from the top to the toe, 
but has buckles and straps by which it can be made to fit closely to the foot 
and leg. The boot leg is studded with whalebone splints, which make it very 
stiff. Two tin cups are fastened to the toe, one on either side. A tin splint 
reaching from near the middle third of the thigh to the lower part of the calf 
of the leg, being longer or shorter, owing to the degree of flexion, or in different 
cases. A tin cup, on either side of this splint, is fixed on a line with those of 
the boot toe. These cups contain spiral springs made of steel. 

" The splint is fixed to the back part of the limb by broad leather straps 
passing around the knee, which are kept in their proper position by loops 
placed at short intervals over the surface of the splint. Wooden rods, of light 
quality, rest upon the springs above and below, so that in the beginning of 
every step the rods are made to compress the springs, which, reacting, com- 
plete the step with very little effort on the part of the patient. When the ap- 
paratus is properly adjusted, it is almost impossible for the patient to sprain 
the limb by a misstep, even if it should be caused by a sudden descent of two 
feet or more. In fact, the limb is so protected that, unless the patient fall 
directly upon the front part of the knee, he is not liable to injury by moderate 
walking, let the joint be as weak as it may." 

In a paper on typhoid or enteric fever, Dr. Ira E. Oatman remarks that 

"This disease prevails along the Pacific coast and around the Bay of San 
Francisco to some extent, in the malarious valleys of the Sacramento, and ex- 
tensively in the higher altitudes of the mining regions and the mountains. It 
mostly affects the young and middle-aged, and is exceedingly variable in its 
mode of attack, its prevailing symptoms, its progress, and termination ; its 
fatal effects being often wrought before any positive indications are manifested 
of their existence. Although it is stated in books that the disease is easily 
controllable by treatment, I do not often find it so ; for even the cases which 
recover seem to be little affected by the treatment employed. I have treated 
this disease medically and hygienically through its whole course, and almost 
wholly without medicine, with little apparent difference in the results. Yet I 
am fully convinced that medicine is beneficial in most cases — if not at all times, 
still it is highly useful to meet the various indications during its continuance. 
With a single exception, the purely expectant treatment has given me the best 
satisfaction. 

" This exception is important, as it is not usually indicated by the direct 
symptoms, but must be determined from a knowledge of the history of the case. 
If the patient has resided in a malarious district within many months of the 
attack, whether the fever is obviously remittent in its type or not, it is gene- 
rally benefited, in a majority of the cases, by the liberal use of quinia sulphas. 
Those who do not improve during its administration are, to say the least, not 
injured by it. I usually combine with it the pulv. ipecac, et opii, in the pro- 
portion of gr. v of the former to iv or v of the latter, for each dose, and, the 
bowels being freely open, give this dose every four hours for about two days. 
This treatment, in some cases apparently typhoid, will entirely eradicate the 



212 



BiLliograjphical Notices. 



[Jan. 



fever, and with it all its consecutive affections, proving that the fever was 
purely malarious in its origin. But when the most favourable result does not 
follow its use, still the heat of the skin abates, the aching pains in the head, 
back, limbs, etc., subside, the tongue and mouth become more moist, and the 
pulse reduced in fulness and in frequency, from 100 or 120 to 70 or 80 in a 
minute. 

" This state often lasts for two or three days, thereby removing, in a great 
measure, for the time being, the danger of serious local disease. But if the 
fever is not purely malarious in its origin, or if so, and follicular inflammation 
is already fully established in the mucous membrane of the bowels, then the 
avenues through which the nutrient properties of the ingesta reach the blood 
being partially or wholly obstructed, the blood becomes impoverished, the 
brain and nervous system become irritable, the heart and arteries act more 
rapidly, and we have a fully developed case of enteric fever, but one more sim- 
ple and less dangerous than it would have been without the action of the 
quinia, &c, in removing the malarious influence.'" 

An interesting case in which both the internal iliac artery and vein were in- 
cluded in a ligature, is related by Dr. E. S. Cooper. No bad effects resulted, 
the patient recovered completely and rapidly. Some remarks are appended 
to the case in reference to the propriety of ligating "the satellite veins in con- 
junction with the arteries which they accompany, in all cases in which a liga- 
ture is demanded." 

The report of the committee on obstetrics, by Dr. H. Gibbons, of San Fran- 
cisco, presents a hasty sketch of the general causes which render so common 
the prevalence of uterine disorders in California. These causes, according to 
the reporter, are such as have a tendency to produce an undue excitement 
of the female organs of reproduction. The potency of these causes 

" Was soon observed in the frequency of conception among women who had 
for years ceased to bear children. It was not uncommon for friends who had 
relinquished the duties of the nursery for five, ten, or even fifteen years to find 
themselves unexpectedly called to resume those duties. It was also exhibited 
in the frequency of twin births, the greater tendency to miscarriage and to 
uterine hemorrhage, the derangements of the menstrual function, and the count- 
less host of neurotic maladies of uterine origin, so harassing to patients and so 
perplexing to physicians. 

" That infants at birth are above the average size in California is attested by 
many accoucheurs. Ten pounds is a very common weight, and in my practice 
of six years two children have been born weighing respectively 12j and 13 
pounds, either of them larger than any child that I had delivered in nearly the 
same range of obstetric practice in Wilmington and Philadelphia during 
twenty-two years." " Twins, I believe, are indisputably more frequent than 
in the old States, and triplets are by no means unheard of." 

Dr. Gibbons presents a mournful picture of the practice which prevails 
among pregnant females of procuring abortion to rid themselves of the pain, 
cost, and annoyance of gestation, parturition, and lactation. 

" The extent," he observes, " to which this practice prevails in California is 
disgraceful. Married women often appear much more alarmed to find them- 
selves pregnant than maidens. Every physician must have encountered the 
most anxious and distressed inquiries on the subject. Not only does the prac- 
tice pervade the circles of fashionable life, but it exists among women who 
acknowledge in the general tenor of their conduct the restraints of morality 
and religion." 

" Miscarriages," Dr. G. informs us, " were more frequent six years ago than 
now. In San Francisco they were attributed to the hilly and sandy walking. 
Hard work at the wash tub and ironing table, and other drudgery, to which 
delicate women have been subjected, aided in producing the result. But there 
was evidently an inherent cause deeper than this — a strong tendency to ute- 
rine hemorrhage has been observed in connection with miscarriages. 

"Beyond all due proportion to the number of births is the number of still- 
born children. This is partly owing to the frequency of untoward presenta- 
tions, and of preternatural and complicated labours. But mismanagement 



1858.] 



American Insane Hospital Reports. 



213 



and neglect do much more mischief. This branch of practice is greatly in the 
hands of ignorant women and inexperienced men, whose services are valued 
because they are cheap. Human life in general being set at a low valuation 
in California, such results might naturally be anticipated. Besides, there is a 
want of the proper maternal instinct, or, at least, a low degree of it, in a 
very large number of women. They are averse to the care and burden of off- 
spring, and their indifference or dislike has its natural results, not only in the 
large proportion of stillborn children, but in the great mortality after birth 
and during infancy. 

" Mammary tumours and abscesses are common, and, as a consequence, 
many infants are deprived of the natural and most healthy fountain of nutri- 
ment. This adds slightly to the infantile mortality." 

" Apart from the direct influence of the uterine system on the brain and 
nerves, which operates with undue force, the nervous organization is subjected 
to greater excitement from other causes in this country than in older settle- 
ments. From the exalted sensibility thus established, it might be inferred that 
puerperal convulsions are not uncommon. Such appears to be the fact. I 
may add, that chloroform and ether have relieved a number of unpromising 
cases of this description. In one instance in my charge about two years ago, 
I kept the patient for several hours under the moderate influence of ether. 
The remedy was resorted to after the failure of other potent remedies, and to 
it I attribute the saving of a valuable life. Conjoined with venesection, the 
anaesthetic treatment is generally safe and efficacious, if not pushed too far. 

" Fever is a common attendant on the puerperal state. In the large propor- 
tion of cases it assumes an intermittent form, or a remittent bordering on an 
intermittent, and yields readily to quinia. Peritonitis, if it exists at all, is not 
often a prominent symptom in these cases." 

A case of successful ligature of the common carotid is related by Dr. K. 
Beverly Cole, of San Francisco. The ligature was applied for the arrest of 
hemorrhage, in an extensive incised wound of the posterior and left side of the 
neck, opening the pharynx and larynx, and in its course severing the internal 
carotid or one of its larger branches. In five weeks subsequent to the opera- 
tion, the patient was attending to business as usual. D. F. C. 



Art. XVIII. — Reports of American Institutions for the Insane. 

1. Of the Friends 7 Asylum, Philadelphia, for the fiscal years 1855-6 and 

1856-7. 

2. Of the U. S. Government Hospital, for the fiscal year 1855-6. 

3. Of the Ohio Central State Asylum, for 1856. 

4. Of the Ohio Northern State Asylum, for 1856. 

5. Of the Ohio Southern State Asylum, for 1856. 

1. "The house," says Dr. Worthington, of the Friends' Asylum, Philadel- 
phia, in his report for the fiscal year 1855-6, " has been as full, throughout the 
year, as was consistent with the comfort and welfare of its inmates ; and, per- 
haps, during no similar period have the designs of the contributors been more 



fully carried out." 

Men. Women. Total. 

Patients at the commencement of the year . 59 

Admitted in course of the year ... 24 11 35 

Whole number 94 

Discharged, including deaths .... 28 

Remaining, March 1, 1856 .... 66 

Of the patients discharged, there were cured . 14 

Died 4 



214 



Bibliographical Notices. 



[Jan. 



The following truly remarkable statement is made respecting the patients 
deceased : " One man and three women have died during the year. The first 
was in his eightieth year, and died from the effects of old age ; one of the 
women was seventy-nine years of age, and died of paralysis ; the second was 
seventy-seven years old, and died of exhaustion from long-continued excite- 
ment ; the third was in her ninetieth year, was deaf, dumb, and idiotic, and 
died of an attack of diarrhoea." 

It is to be hoped that the time is not far distant at which the superintend- 
ents of all the hospitals for the insane may be enabled, like Dr. Worthington, 
to write as follows: — 

" It is gratifying to observe the improvement that has taken place within the 
last few years, both in regard to placing the insane under medical treatment 
at an early period of the disease, and also in allowing them to remain a suffi- 
cient length of time to afford them a fair opportunity to derive all the benefit 
the institution is capable of conferring. It is but seldom we have to lament 
the premature removal of a patient, except when the pecuniary circumstances 
of the individual forbid his longer continuance." 

The results of this year " correspond with the experience of previous years, 
in showing that about one half of those who recover are discharged within 
three months from the time of admission ; that the term of six months nearly 
represents the average duration of successful treatment, and that a considera- 
ble number recover after having been under treatment for as long a time as 
twelve months. It may be mentioned as an inducement for persevering in the 
use of remedies, that the recoveries which take place gradually, and occupy 
the longest time, are often the most satisfactory and permanent." 

In regard to mechanical restraint, it is remarked that " 1 the sleeves/ (cami- 
sole?) made of soft material, is the only form in which it is used among our 
patients, and, during the last six months, no case has occurred in which it was 
deemed necessary, or was resorted to." 

In an asylum like that the report from which is before us, where all the reci- 
pients of its benefits are " pay patients," it is much more difficult than in 
State, County, or City institutions, extensively to introduce a system of manual 
labour, or employment. Especially is this true in respect to the occupants of 
the department for females. From the subjoined extract we infer that this 
difficulty has been, measurably at least, overcome at the Friends' Asylum. 

" A few of the female patients engage in assisting the attendants in their 
household duties in the wings; but the greater number occupy themselves in 
knitting, and the various kinds of needlework. The most of the clothing of 
the female patients has been made up in the institution, and a large number of 
garments for the poor, the materials for which were furnished by a friend in 
the city, have also been made. The advantages of occupation have been par- 
ticularly observable during the past year among the excited class of female 
patients, some of whom, by persevering exertions on the part of the matron 
and attendants, have been induced to engage in it." 

It is universally acknowledged that of all the elements constituting what is 
called the " moral treatment" of the insane, manual employment which contri- 
butes to some useful or beneficent object or end, is the most beneficial. Hence 
its extensive application is of paramount importance. We have found, by 
experience, that much may be effected towards the object of inducing all the 
patients of adequate physical ability to engage in it, by giving currency to, 
and constantly sustaining, in the wards, the idea that such employment is 
expected from every one ; that it is a part of the established routine; and that 
he who refuses thus to occupy a portion of his time, disregards one of the 
wholesome regulations of the establishment. 

Among the additions to the means of entertainment of the patients at this 
asylum, are two of Lloyd's Stereoscopic Cosmoramas. Within a few months 
we have seen this convenient apparatus for the exhibition of photographic pic- 
tures at several of the hospitals for the insane. 

The report for 1856-7, like that of the preceding fiscal year, is ornamented 
with two fine pictures; one, a front view of the asylum, the other a view of 
the garden and library. 



1858.] 



American Insane Hospital Reports. 



215 



Men. Women. Total. 



Patients in the asylum, March 1, 1856 . . 66 

Admitted in course of the year ... 20 16 36 

Whole number 102 

Discharged, including deaths .... 44 

Remaining March 1, 1857 .... 58 

Of the patients discharged, there were cured . 21 

Died 9 



We hope that our friend, Dr. Worthington, will introduce into his reports, 
hereafter, some method by which the whole numbers, of each sex, who have 
been in the asylum in the course of the year, can be ascertained. Many im- 
provements have been made in the organization, and the internal economy of 
the institution during his administration : can he not now find time to revise 
and reform his antiquated form of published statistics? 

We quote, nearly entire, the doctor's remarks upon the " forms of insanity." 

" In the nomenclature of the disease, I have preferred retaining the generic 
names of Mania, Monomania, Melancholia, and Dementia, rather than adopt- 
ing a more minute subdivision which, however it may appear more scientific 
than the older method, scarcely answers as well all the purposes of classifica- 
tion. If these terms do not express accurately the nature of the disease, they 
are, as it were, consecrated by long established usage, and have at least the 
merit of being intelligible. It is difficult sometimes, at first, to decide under 
which of the above heads a given case shall be classed, from the fact of the 
changing phases of the disease ; a case occasionally in its progress exhibiting 
the character of two or more of the above forms. Thus a patient affected with 
monomania, under some real or imaginary provocation, will break out into the 
excitement and violent acts of mania; the depression of melancholia, though 
essentially distinct, in some cases bears a close resemblance to the inertia of 
dementia; some of the demented are subject to paroxysms of maniacal excite- 
ment; and even the deep dejection of melancholia alternates, in some instances, 
with the elevation of self-pleasing monomania. These changes show that the 
above-named do not indicate so many distinct diseases, but rather varying 
forms of one and the same disorder. Yet, in most of these cases, there are 
predominant features which assign the patient to one of the above forms in 
preference to the rest. 

" One reason for the above classification of insanity, is the avoidance of the 
term ' moral insanity,' which has been so greatly misunderstood and perverted 
that it would, perhaps, have been better had it never been invented. As gene- 
rally understood, this term conveys the idea of a condition in which patients, 
without any impairment of their mental integrity, are so much under the con- 
trol of some evil propensity as to be utterly powerless to resist it, and conse- 
quently irresponsible for any act committed under its influence. There may 
be cases of insanity in which a disposition to immoral conduct is conspicuous, 
and in which mental disorder may not be very apparent; yet to say that the 
indulgence of this disposition is of itself any evidence of the disease called 
insanity, shows very confused ideas on the subject. The habitual indulgence 
of bad passions may lead to insanity, but when this condition is reached, it is 
manifested by other signs of mental impairment than mere inability to resist 
them. Perverted sentiments and excited passions, though not alone constitut- 
ing insanity, do often, however, enter largely into its manifestation. The 
proneness of maniacs to irritation and anger, and their disposition to fancy 
themselves the objects of actual or intended wrong, are among the forms under 
which self-love manifests its predominance. The delusions of the monomaniac 
often show the effects of inordinate self-esteem, and anxiety for promotion and 
honour among men." 

We cannot agree with Dr. Worthington in the desire to avoid the term " mo- 
ral insanity." Unquestionably, there are cases in which perversion of the sen- 
timents is as prominent and distinguishing a characteristic of the disease, as 
are high excitement, vociferation, violent gesticulation, and turbulence, in acute 
mania. We would, therefore, not only not avoid the term in question, but use 



216 



Bibliographical Notices. 



[Jan. 



it as frequently as convenience may require, if but for the purpose of establish- 
ing in the minds of men the fact of the existence of such a disease. This fact 
has been doubted, disputed, denied, ridiculed ; not among the laity alone, but 
by members of the several professions, and even where it should be doubted 
least, upon the judicial bench. Let, then, those persons whose professional 
position best enables, and most requires them to do it, continue their exposi- 
tions of the disease until it shall be generally recognized. 

In the remarks upon " Occupation" in the report before us, it is stated that 
" experience teaches that three or four hours each day is as much as can gene- 
rally be required/' advantageously, of the patients. 

" There are but few cases in which there is not discernible some derange- 
ment of one or more of the organs or functions of the body, which must be 
met by appropriate medical treatment. In most cases, tonic medicines and 
those calculated to allay nervous irritation, are requisite ; while those of an 
opposite character, as are all depressing remedies, must be carefully avoided. 
The cases in which bloodletting would be beneficial, are extremely rare ; while 
in a large majority it would be decidedly injurious. 

"One of the large rooms on the first floor of the centre building has been 
fitted up with seats and cases, and other necessary fixtures of a lecture-room, 
for the use of the patients. The philosophical apparatus has been removed to 
this room, thus affording increased facilities for demonstrating some of the 
familiar principles of natural science." 

2. The annual report from the Government Hospital for the Insane, near 
Washington D. C, is signed by Dr. Benjamin S. Bohrer, President of the 
Board of Visitors, and Dr. C. H. Nichols, the Superintendent. 

Patients in the Hospital July 1, 1855 
Admitted in course of the year 

Whole number 

Discharged, including deaths, . 
Remaining July 1, 1856 . 
Of those discharged, there were cured 
Died 



Men. 


"Women. 


Total. 


26 


34 


60 


36 


11 


47 


62 


45 


107 


8 


6 


14 


54 


39 


93 


3 


2 


5 


4 


4 


. 8 



We quote the following extract from the report, because it relates to a sub- 
ject heretofore unmentioned, so far as we recollect, in any of the American 
reports. 

" Only five, or about 8 per cent, of the sixty-three persons admitted before 
the commencement of the Hospital year to which this report relates, had been 
insane for a less period than one year at the time of admission ; while of the 
forty-seven admitted this year, nineteen, or about 40 per cent, had, as well as 
could be ascertained, been insane less than one year, and were more or less 
hopeful in respect to recovery. 

" This very satisfactory improvement in the character of the patients re- 
ceived the past year, is likely to continue for two or three years to come, when 
the proportion of recent cases to the whole number admitted will reach its 
maximum of about 64 per cent., as is made to appear in a late report of the 
celebrated Friends' Retreat, near York, England, which now sums up a very 
carefully recorded experience of sixty years. 

" It might at first appear that when a particular institution has been in 
operation long enough to receive all the protracted cases which had accumu- 
lated in the absence of convenient provisions for their accommodation, the sub- 
sequent admission from the vicinage would be mostly cases of short duration ; 
but a little reflection will render it apparent that the experience of that ancient 
establishment, just cited, is perfectly consistent with the probabilities every- 
where. 

" The thousand refined dissipations of modern civilization give rise to many 
cases and forms of mental derangement whose existence is at first debatable, 
and as it has often happened in the past, so it will probably continue often to 



1858.] 



American Insane Hospital Reports. 



Ill 



happen in the future, that the timidity, or affection, or pride, or cupidity, or 
inability of friends, will defer a resort to hospital treatment till the disease 
becomes as confirmed as it has long been apparent and troublesome." 

Some of the peculiarities of the Government Hospital, and some of the ad- 
vantages springing therefrom, are thus alluded to :- — 

"That this establishment will afford a home for life for all its incurables ; 
that they are separated from their friends, and are independent of them, and 
dependent upon the institution ; that the soldier and the sailor are habituated 
to obedience and order; are all circumstances which, taken together, are cal- 
culated to give us a more complete and easy control of the time and habits of 
our patients than has hitherto been practicable in any American Hospital for 
the Insane. It is our aim as a permanent policy, to turn these favorable cir- 
cumstances to account in effecting the gradual engagement of all our incurables 
who have been accustomed to any form of manual labor, in some wholesome 
and useful employment. 

" Our efforts thus far have been encouraging beyond our most sanguine ex- 
pectations. No accident has happened, though several patients have been 
intrusted with tools who had previously been deemed dangerous. Refreshing 
and sound sleep has taken the place of the most vicious indulgences ; pallor and 
listlessness have given way to ruddiness and strength; and, above all, increased 
interest in life and its objects and affairs, has added light to the eye and anima- 
tion to the step. Indeed, we have often been astonished to observe how the 
industry and good conduct of our patients have kept even pace with the encour- 
agement and confidence they have received at our hands." 

3. The Eighteenth Annual Report of the Trustees and Officers of the Central 
Ohio Lunatic Asylum, at Columbus, is a pamphlet of seventy-six large duo- 
decimo pages ; and yet it furnishes but little matter which comes within the 
usual scope of our notices. The superintendent, Dr. R. Hills (superintendents 
succeed each other at this institution almost as frequently as the annual reports), 
occupies a large part of his report by an exposition of the " wants" of the 
Asylum. We proceed to make some extracts. 

"But little can be said of our farming. The principal portion of our farm 
is but slightly removed from a state of nature, it being in the condition of what 
is usually termed a woods pasture. 

" An abundance of water in such an institution is indispensable. Our 
arrangements therefor are very imperfect, troublesome, and expensive. Much 
of the time during the past summer, it has been necessary to economize its 
use carefully, and a portion of the time it has been necessary to carry it into all 
parts of the house by hand. 

" The barn ' is a wooden structure/ at this time in a state of complete dilapi- 
dation, and it is with regret that we are compelled to use it for even another 
winter. 

" Workshops for a variety of mechanical operations are found in most other 
institutions, got up for the benefit of patients. Ours has none I That at Utica 
has a printing office. * * * * There are also cabinet shops, turning lathes, tailor 
and shoemaking shops, &c. Other institutions are similarly provided ; but 
what have we ? Absolutely nothing ! Not even a shoe-bench. 

" As many as ten years since there were over six hundred volumes in the 
library, and it was then the practice to make yearly appropriations to increase 
the number. Now, the entire miscellaneous library comprises less than 275 
volumes. Those in any manner touching the subject of insanity, number 31 
volumes. Those on medical and scientific subjects, 37 volumes. They are 
old, and most of them have little value. 

" There is not a single sofa in the patients' halls ; there are three lounges of 
domestic manufacture, hard and uncomfortable, and six split-bottomed rocking 
chairs, with one wooden one in the eastern hall, for the comfort and convenience 
of one hundred and twenty-five females ! There is scarcely a log-cabin in Ohio 
that is not better provided in these respects." 

These extracts are sufficient to convince the reader of the decadence of the 
institution at Columbus, an institution which, during the first twelve years of 



218 Bibliographica I Notices. [Jan . 

its existence, sustained its position amongst the best of the kind in the United 
States. This decadence is acknowledged by Dr. Hills, in the remark, " had the 
asylum been originally intended for or purposely permitted to degenerate into 
a mere receptacle for the incurable insane, where the simple physical wants 
and ordinary necessities of life were to be provided for with even a generous 
hand, then could I say that those for whose benefit it was created are as well 
provided for as it is possible for them to be under any circumstances, or in any 
institution of the country. But it is otherwise. It has a much higher aim. 

" The question," he continues, " as to what, where, and when have been the 
influences that have lost to us our former pre-eminence, it is not proper for me, 
nor am I disposed, to discuss. I will only say, that without an intelligent, 
active, and faithful superintendence; a wise, liberal, and harmonious directory ; 
a generous and open-handed legislation ; and, with all, and over all, a Divine 
sanction, we cannot expect success." 

Unhappily this institution has been so wholly controlled by partisan politics 
that, in the course of seven or eight years, it has had a succession of no less 
than five superintendents, most of them elected in conformity with the modern 
political dogma, " to the victors belong the spoils." Dr. Hills has given a long 
detail of the "wants" of the Asylum, and says, "to specify all our wants would 
be too tedious." Among those which are not specified are the first, the greatest, 
the most important. These are separation from partisan politics, and a compara- 
tively permanent superintendent. Supply these two primary and radical neces- 
sities, and the number of other " wants" would very rapidly decrease. 

Patients in the Asvlum, Nov. 15, 1855 
Admitted to Nov. 1st, 1856 

Whole number 

Discharged, including deaths . 
Remaining, Nov. 1st, 1856 
Of those discharged, there were cured 
Died 

Causes of Death. — Phthisis puimonalis, 3 ; apoplexy, 3 ; typhomania, 3 ; epi- 
lepsy, 3 ; hemorrhage from bowels, 2; dysentery, 1 ; organic disease of brain, 
1 ; anasarca, 1 ; anaemia, 1. 

Throughout the year the inmates enjoyed " an unusual exemption from epi- 
demics, and even the ordinary diseases of the climate and season." 

All statistics prior to the last fiscal year, are omitted from this report. 



Men. 


"Women. 


Total. 


109 


107 


216 


68 


86 


154 


177 


193 


370 


75 


72 


147 


102 


121 


223 


30 


34 


64 


9 


9 


18 



4. On the 1st of December, 1854, Dr. L. Firestone commenced his duties 
as superintendent of the Northern Ohio Lunatic Asylum, at Newburg. On the 
5th of March, 1855, the first patient was received. On the 5th of August, 1856, 
Dr. Firestone was subjected to the political guillotine, and his place filled by 
Dr. R. C. Hopkins. 

On the 14th of August, Dr. Jacob Laisey was appointed assistant physician, 
and Mr. E. H. Doolittle steward. 

Judging of the future by the past, the official existence of Dr. Hopkins will 
be coextensive with the predominance of the party which has borne him into 
office. 

From the 5th of March, 1855, to the 31st of October, 1856— 



The number of patients admitted was 
Discharged, including deaths . 
Remaining Nov. 10, 1856 
Of those discharged, there were cured 
Died 



Men. 


"Women. 


Total. 


]26 


160 


286 


60 


87 


147 


66 


73 


139 1 


47 


57 


104 


4 


11 


15 



1 The statistics in the Report, instead of being given in one place, by the super- 
intendent, are partly included in the report of that officer, and partly in that of the 
trustees. Dr. Hopkins states the number remaining on the 1st of Nov. to be 141. 



1858.] 



American Insane Hospital Reports. 



219 



" During the first two weeks of our occupancy of the house," remarks Dr. 
Hopkins, " a few cases of dysentery, of a mild form, occurred. Fortunately no 
deaths occurred from this cause." 

" The year just past has shown a steady increase in the number of those 
seeking relief in the asylum, so that at its close, we find it crowded to the full- 
est possible capacity. * * * The number of applicants on file (25) which we 
have been unable to accommodate, gives us no hope of a less average than for 
the past three months. 

From the state of things in Ohio, during the past few years, we infer that the 
new hospitals were erected upon contracts, the giving of which was in the 
hands of political partisans. Hence we are not surprised at the subjoined 
language of the report: — 

" The repairs upon the buildings and out-buildings have been expensive, and 
still more expensive ones will be required in the year to come, or parts of the 
buildings must go to speedy decay. This may appear almost incredible of 
structures so nearly new. Yet the fact is plainly visible to the most casual 
visitor. Among those which have been made, or are now in progress, the re- 
building of the gas-well is most prominent. The gas-house can hardly be kept 
from falling until spring, and it will be necessary to rebuild nearly or quite the 
whole structure then, if not before." 

" The removal of the barn and other out-buildings to a uniform and more 
convenient locality, promises to add much to the comfort of our stock, and those 
having them in charge." 

" I am satisfied that prudence and economy would dictate the substitution 
for the present rickety and badly-geared pump, a larger and more simple ma- 
chine." 

" A change of the kitchen and bake-room, from their present smoky, out-of- 
the-way location, directly over the boilers, to a more central and convenient 
one, is desirable — I might say absolutely indispensable. The fixtures of these 
apartments will need to be nearly all replaced, somewhere in the approaching 
spring." 

All this is exceedingly encouraging information in regard to an establishment 
which had been in operation but one year and eight months, and which was 
constructed at a time when the knowledge of the best and most convenient 
architectural arrangement of buildings and apartments for the insane had 
arrived at a high degree of perfection. 

5. Dr. Joshua Clements was the superintendent of the Southern Ohio Luna- 
tic Asylum, at Dayton, from the time of its opening, September 1st, 1855, until 
the 1st of May, 1856, the somewhat protracted period — protracted for Ohio — of 
eight months. The star of his political opponents having now gained the 
ascendant, he was "for such a worthy cause" removed, and his place supplied 
by Dr. J. J. Mcllhenny. 



Patients in the Asylum, Nov. 1, 1855 
Admitted in course of the year 
Whole number . . . 
Discharged, including deaths . 
Remaining, Nov. 1st, 1856 



Men. 


"Women. 


Total. 


23 


23 


46 1 


87 


88 


175 


110 


111 


221 


40 


44 


84 


69 


64 


133 2 



Causes of Death. — " Apoplexy, 1 ; exhaustion, 2 ; inanition, 1 ; hemorrhage 
of bowels, 1 ; chronic dysentery, 1 ; apnosa, 1 ; chronic gastritis, 1 ; disease of 
heart, 1 ; tabes mesenterica, 1. 

The Italics of "apnasa" are ours. Some light is probably thrown upon this 
case by the following statements, on a subsequent page of the report: " One of 
our number committed suicide, by hanging himself to the window in his room, 

1 According to the report of the preceding year, 48. 

2 This line is given as in the report, although from the figures above it, it should be 
70—67—137. 



220 



Bibliographical Notices. 



[Jan. 



with a strip torn from a sheet on his bed. He was early discovered, but too 
late for resuscitation." 

"In the months of May and June, erysipelas seized upon a number of our 
patients, in quite a severe form, and at one time, threatened to seriously invade 
the whole house ; but, by strict attention to cleanliness and regimen, it ceased 
its violence, assumed a sporadic character throughout July and August, and 
finally disappeared from the house, without producing any deaths, or any very 
deleterious results." 

Our business with the reports of the public institutions for the insane, relates 
more to the matter which those reports contain, than to the manner in which 
that matter is conveyed. Yet, when we meet with language like that of the 
following extracts, we cannot help wishing that a little more care had been 
taken. 

" There have been three elopements the past year." 

ii The relation of mind and body are so intimately and intricately blended 
that neither can suffer injury without the other. The sympathetic relation 
existing between the complex machinery of our systems is so mysterious in its 
workings, that, to fully understand and comprehend the influences which, in 
this way, may be exerted upon the mind, involves facts which have been, per- 
haps, too little studied, even by medical men. 

" The idea that it was rather disgraceful to send a near and dear relative to 
an insane asylum has now, happily, but few advocates. But, on the con- 
trary, at the very first onset of dethroned reason, many persons now are 
not only willing, but solicitously anxious to have them cared for in a place of 
this kind. 

" Such a state of public sentiment needs not only encouragement, but a 
care to instil it into the minds of the community." 

Dayton, like Newburg, furnishes some of the beauties of buildings of which 
politics is the foster-mother. 

"It is impossible," say the trustees, " to wash the floors without endanger- 
ing the plastering below. They were made, as the large cracks indicate, of 
unseasoned or wet material." 

"The cooking ranges were worthless. Their place has been supplied by a 
cooking stove." 

" Last winter it was found impossible to warm comfortably the four wards 
then in use, though one hundred bushels of coal and five cords of wood were 
daily consumed. We have been obliged to have the boilers reset, and new 
castings provided for their fronts. * * * Attempts have been made to remedy 
other important defects in the heating apparatus." 

" The water-closets are defective ; health and comfort require their re- 
modelling. 

" The pumps and pipes now in use for elevating the water to the tanks in 
the attic, are too small to furnish the necessary supply. New ones have been 
ordered." 

" The roof on many parts of the building leaked badly. After several in- 
effectual attempts to remedy it without, we deemed it necessary to put an 
entire covering of tin on the dome, and have contracted for the work." 

" Owing to the leaking of the roof and floors, much of the plastering has 
fallen, and must be replaced." 

" There is a great defect in the system of ventilation for the whole house, 
and particularly the wards. A small sum expended for the purpose might 
effect a great improvement, though it is now impossible to render it as perfect 
as it might, and ought to have been made in the construction of the building." 

" From the basement to the cupola the locks were of a bad quality. The 
most worthless have been removed, and better ones substituted." 

We have now completed the task — a most disagreeable one, it is true — of 
presenting to our readers some of the defects of the three State Institutions of 
Ohio, as they are represented by their trustees and executive officers. Those 
institutions stand as the monuments of a most deleterious policy — a policy 
which blasts every philanthropic establishment into the management of which 



1858.] 



American Insane Hospital Reports. 



221 



it is introduced — a policy which we shall continue to denounce, wherever and 
whenever, and by what political party soever it may be adopted. "We saw the 
New York City Lunatic Asylum when it was under the political regime, and 
we have seen it years after its emancipation therefrom. It presented, at the 
two different times, a most remarkable contrast. The popular ideas of the two 
opposite states in the future world are scarcely more dissimilar. The Xew 
York Institution is regenerated ; and the institutions of Ohio are in the path 
which, if long pursued, will reduce them to its former condition. Such a re- 
salt is inevitable. 

The superintendents of the institutions in Ohio will observe that we are 
writing against a principle of action which, although it may have brought them 
into office, does not necessarily in the least affect their qualifications for those 
offices. 1 They may be, for aught we know, better adapted to the peculiar posi- 
tions which they occupy than any other persons in Ohio. Personally, we have 
no acquaintance with either of them, yet we hope that, if they be properly 
qualified for their places, they may retain those places until the institutions 
under their care shall rank among the best in the country. Dr. Hopkins has 
had considerable experience in the business as Assistant Physician at the 
Central Ohio Asylum ; and the elaborate report of Dr. Hills very clearly de- 
monstrates that he understands the necessities of an establishment for the 
insane. 

The buildings of the two new hospitals in Ohio are not the only ones of the 
kind, in this country, which were shabbily constructed. All such edifices, if 
built by contract, are very likely to be defective in the extreme. The building 
of the Pennsylvania State Hospital for the Insane, although but six or seven 
years of age, is already feeble, decrepid, rickety, superannuated, and will soon 
be unable to sustain its own weight without additional assistance. A structure 
of the kind ought to be intended for the wear and tear of centuries. 

Unseasoned lumber has been used in many of the recently erected hospitals. 
Hence, in many places where joints should" be perfectly tight, there is suffi- 
cient space to admit the finger. There are base-boards with an opening of 
from one-half to three-quarters of an inch between them and the floor, and 
doors with the panels shrunk so far out of the frame that you may thrust your 
hand between them. Much has been said and much has been written upon 
the subject of ventilation. This is well ; and every properly constructed hos- 
pital should be supplied with some means for changing the air, which for- 
merly was not taken into consideration by the architects. But if the buildings 
are to be like some to which we have alluded, all this extra labour and expense 
is unnecessary. The greatest difficulty will be to prevent the air from being 



1 Since the above was written, we have been informed that in the appointment of 
Dr. Hopkins to the superintendency of the Asylum at Newburg/ political party con- 
siderations were waived. He obtained his office simply for the reason that he was 
qualified for the performance of its duties. How strangely soever it may appear to 
the citizens of Ohio, that a man should succeed, by so novel a process, in getting into 
a place of responsibility and profit, we trust that the result will be such as to induce 
those who have the distribution of offices in the benevolent institutions, to persevere 
in their commenced course of well-doing. 



changed too rapidly. 



P. E. 



No. LXIX.— Jan. 1858. 



15 



222 



Bibliographical Notices. 



[Jan. 



Art. XIX. — American Surgical Tracts. 

1. Remarks upon Fractures of the Scapula, with Cases presenting Striking 
Peculiarities. Read before the Medical Society of the State of Georgia, at 
their Annual Meeting in Augusta, 1857. By L. A. Dugas, M. D., Professor 
of Surgery in the Medical College of Georgia. 8vo. pp. 22. 

2. Early History of the Operation of Ligature of the Primitive Carotid Ar- 
tery, with a Report of Forty-eight Unpublished Cases, and a Summary of 
Forty-four Cases, with Remarks by Valentine Mott, M. D. By James It. 
Wood, M. D., Surgeon to Bellevue Hospital, President of the N. Y. Path. 
Society, etc. etc. (Reprinted from the N. T. Journ. of Med. for July, 
1857.) 8 vo. pp. 59. 

3. An Inaugural Thesis on Intra- Capsular Fractures of the Cervix Femoris. 
By John G. Johnson, of the State of Massachusetts. (Reprinted from 
the New York lournal of Medicine for May, 1857.) 8vo. pp. 32. 

4. Surgical Cases, communicated to the Boston Society for Medical Improve- 
ment, Oct. 27, 1856. By George H. Gay, M. D., one of the Surgeons of 
the Massachusetts General Hospital. (Republished from the Boston Med. 
and Surg. Journal, November, 1856.) 8vo. pp. 24. 

5. Report of an Operation for Removing a Foreign Body from beneath the 
Heart. By E. S. Cooper, A. M., M. D. (Published by the San Francisco 
Medico-Chirurgical Association as an additional paper to its Transactions 
for the year 1857.) San Francisco, 1857. 8vo. pp. 8. 

1. The object of the paper of Professor Dugas, as stated by the author, is " to 
take a hasty view of the injuries to which the scapula may be subjected, to 
direct special attention to fractures of the neck of this bone, and to relate two 
cases presenting important peculiarities hitherto unnoticed by systematic 
writers." 

Fractures of the scapula are rare, and those implicating the neck of the bone 
really demand the special attention of surgeons, for there are many obscure 
points connected with them to be elucidated. The rarity of fractures of this 
bone may be inferred from the statistics of Middlesex Hospital and of Hotel 
Dieu, which are cited by Professor Dugas. In the latter, in 2,358 cases of 
fracture, there were but 4 of the scapula; in the former, out of 1,901, there 
were 18. The proportion of the Middlesex Hospital is slightly greater than 
that we have found to exist in the Pennsylvania Hospital. In the Fracture 
Book of this Institution, from December 6, 1852, to October 20, 1857, 1,578 
cases of fracture are recorded, and of these 14 are of the scapula. In the Mid- 
dlesex Hospital, 8 of the fractures implicated the body, 8 the acromion apo- 
physis, and 2 the neck of the bone. In the Pennsylvania Hospital they are 
thus marked: 4 of the acromion; 2 of the dorsum; 4, just below the spine; 
1, of the spine about the middle ; 1, through the spine and the upper and lower 
fossae ; 1, of the inner and upper angle ; and 1, of the neck. The fracture of 
the neck was in a child two and a half years old, who fell from a table ; the 
direction of the fracture is marked as uncertain. In all these cases, with the 
exception of one in which the dorsum was pierced through, and the inferior 
angle broken off by a load of shot that passed in the axilla, some under, some 
over the scapula, the injury was the result of a violent fall upon the shoulder 
or back, or the receipt of a violent blow upon those parts. 

Professor Dugas studies these fractures separately as they occur in the body 
of the bone, its spine, its processes, or its neck. For those of the body, the 
spine, and the processes, we find the same directions as to diagnosis and treat- 
ment as those usually given by authors. It appears certain that the details 
given with so much precision in books of the various displacements, are de- 
duced from theoretical views rather than from direct observation. According 
as the fracture of the bone is higher or lower, the serratus magnus, the teres 
major, and the latissimus dorsi would be supposed to influence more or less 
the position of the fragments. This is not so, however. In the Fracture Book 



1858.] 



American Surgical Tracts. 



223 



spoken of, we find, as a general rule, that there was little or no displacement; 
the only instance of marked displacement is in the case of fracture of the inner 
and upper angle, which was caused by a fall of fifteen feet on the back ; and 
where the fragment was pulled upwards and inwards by the levator anguli 
scapulae. Of course under such circumstances, of all contentive apparatus, the 
best will be that which causes the least annoyance ; and almost always a sim- 
ple scarf, covering the elbow, the arm, and the forearm, is enough, a bandage 
being applied in addition for the purpose of holding those parts against the 
body. 

All solutions of continuity of bones in the vicinity of joints, as has been 
justly remarked by Dupuytren, give rise to numerous errors of diagnosis ; and 
the observation applies with peculiar force to the injuries which occur in the 
immediate neighbourhood of the scapulo-humeral articulation. Every expe- 
rienced surgeon can recall to his recollection cases of injuries of the shoulder, 
in which he felt the greatest difficulty in determining the exact nature of the 
accident. The subject, therefore, of fracture of the neck of the scapula, the 
lesion to which Professor Dugas wishes to direct special attention, and to which 
he has devoted the greater part of his paper, is one of great interest. 

Sir Astley Cooper, in his work on Fractures and Dislocations, in the chapter 
(the xiith) "on fractures near the shoulder joint, liable to be mistaken for dis- 
locations/' treats of fracture of the acromion, and fracture of the neck of the 
scapula, by which he declares that he means fracture through the narrow parfe 
of the bone, immediately opposite the notch of the superior costa. Of this latter 
accident he gives three cases, and he states its diagnostic marks to be three : 
first, the facility with which the parts are replaced ; secondly, the immediate 
fall of the head of the bone in the axilla, when the extension is removed ; and 
thirdly, the crepitus which is felt at the extremity of the coracoid process of 
the scapula, when the arm is rotated. The best mode of discovering the cre- 
pitus is stated to be, for the surgeon's hand to be placed over the top of the 
shoulder, and the point of the forefinger to be rested on the coracoid process ; 
the arm being then rotated, the crepitus is directly perceived, because the 
coracoid process being attached to the glenoid cavity, and being broken off 
with it, although itself uninjured, the crepitus is communicated through the 
medium of that process. In the second of these cases, one in which he was 
consulted by Mr. Alderman Partridge, it was the opinion of that surgeon that 
the fall of the shoulder was owing to a considerable portion of the glenoid 
cavity being broken off. 

The doctrine professed by Sir Astley Cooper concerning the differential 
diagnosis of fracture of the neck of the scapula is discussed by Malgaigne 
(TraitS des Fractures et des Luxations) under the head of Fractures of the 
Glenoid Cavity, in the section upon complex luxations of the scapulo-hu- 
meral articulation, and it is doubtless from the fact that Malgaigne has 
placed what he has to say of this accident in this position that Professor 
Dugas has overlooked it, since he states it as "somewhat remarkable that 
Malgaigne, in his elaborate work upon Fractures, makes no allusion whatever 
to fractures of the neck of the scapula, either anatomical or surgical." Mal- 
gaigne declares that it is very hard for him to believe that the glenoid cavity 
can fall so easily into the axilla, the coracoid process being suspended to the 
clavicle and to the acromion by ligaments of such great solidity; and if it did, 
an infinitely more certain sign would be had in the movements of elevation and 
depression alternatively communicated to the coracoid apophysis, without omit- 
ting the projection in the axilla of the angular, sharp, or* at least irregular 
inferior fragment, and which would be distinguished readily from the head of 
the humerus. " As to the very insufficient signs of Sir A. Cooper," he con- 
tinues, " they appear to me to correspond better with luxation downwards with 
fracture of the glenoid cavity, than with any other lesion." The only case of 
fracture of the neck of the scapula, which Malgaigne seems willing to accept 
as such, is the one reported by Duverney, and cited in the first volume of his 
treatise, at page 511. A young girl, twenty years of age, fell into a quarry, 
where she was found dead; the autopsy showed a fracture which separated from 
the rest of the bone, the neck of the bone and the coracoid process, which is 



224 



Bibliographical Notices. 



[Jan. 



fracture of the neck, as Cooper understands it. We regret that Professor Dugas 
is not better acquainted with Malgaigne's work, both on account of the ques- 
tion as to the exact situation of the fracture in these injuries, and also of the 
important peculiarities presented by the two cases he has reported, which he 
believes hitherto unnoticed by systematic authors. 

After citing the opinions of a number of celebrated surgeons, Professor 
Dugas says : — 

"While it is very evident from these quotations that some practitioners not 
only believe in the possibility of a fracture of the anatomical neck of the 
scapula, but also think that they have seen cases of this accident, their lan- 
guage is not such as to remove all doubt as to their true meaning in those 
cases in which they refer to actual specimens examined after death. J. L. 
Petit thinks he treated a case of fracture near the glenoid cavity — but he made 
no post-mortem inspection, and may. therefore, have been mistaken. John 
Bell's language is too ambiguous to authorize us to conclude positively that his 
specimen was one of this kind. Samuel Cooper, Chelius, Yidal, and Furgusson, 
have neither of them referred to any specimen, but simply believe that this 
fracture has occurred. I do not recollect ever seeing a specimen of this kind, 
and know of no author who unequivocally describes any. We may, therefore, 
reasonably infer that if it does ever take place, it must be exceedingly rare." 

The authorities cited by Prof. Dugas speak most positively as to the existence 
of the fracture of the glenoid cavity, and we are at a loss to discover any am- 
biguity in the language of Bell: " I have met with the accident in practice, 
and have preparations of the fractured bone, so that there can be no doubt of 
this accident sometimes occurring, yet it is very rare." Malgaigne describes 
four cases, and, of course, unequivocally : one by J. Gregory Smith, taken from 
the London Medical Gazette, 1834, vol. xiv. p. 280, where there was a fracture 
of a small portion of the external edge of the glenoid cavity, discovered at the 
post-mortem dissection ; another case which he saw himself in a man who died 
four days after the reduction of an intra-coracoid luxation, in the wards of M. 
Dononvilliers, where the internal edge had been broken off. A third case is 
represented in his XlXth plate, fig. 3, where a fracture of the internal edge 
accompanied an incomplete sub-coracoid luxation ; the patient died four days 
after the accident, and the reduction of the dislocation. In all these cases the 
limb remained in place after the reduction, on account of the small extent of 
the fragment detached. In a fourth case, one of incomplete sub-coracoid luxa- 
tion, represented in plate xxii, fig. 4, the fracture must be considered the 
principal lesion, for it has detached the whole anterior third of the glenoid 
cavity. In such a case as this a special apparatus would be required to main- 
tain the reduced bone in its position, and we would have the three symptoms 
given by Sir Astley Cooper, as diagnostic of fracture of the surgical neck. 

The acromio-coracoid ligament goes from the summit of the acromion to the 
posterior edge of the coracoid apophysis ; the trapezoid, or anterior coraco- 
clavicular ligament, and the conoid or posterior coraco-clavicular ligament 
fasten it to the clavicle ; we do not understand, therefore, how the arm would 
fall considerably, from fracture of the surgical neck of the scapula, unless the 
acromion process and the clavicle were fractured at the same time. In the 
second case, reported by Prof. Dugas, he mentions distinctly that the coracoid 
process evidently followed the upward and downward movement of the humerus, 
and here the clavicle was broken two and a half inches from its acromial ex- 
tremity, and the acromion process at its junction with the spine of the scapula. 
We are fully satisfied that all cases, in which the clavicle and spine of the sca- 
pula were both uninjured, reported as fracture of the neck of the scapula, from 
the immediate return of the deformity of the shoulder, when the force which had 
reduced it was dispensed with, should not be considered as fractures of the 
surgical neck, but as fractures of the glenoid cavity; all cases, in which the 
deformity from the displacement of the head of the humerus is at all con- 
siderable. 

Surgeons are seldom sufficiently precise in their statements of the symptoms 
remarked in cases of fracture and of luxation. Even so correct and careful a 
surgeon as Dr. Morris, in the history of a fracture of the neck of the scapula, 



1858.] 



American Surgical Tracts. 



225 



given in a report of the surgical cases treated in the Pennsylvania Hospital, 
printed in the xxiiid vol. of this Journal (for 1838) does not mention the cora- 
coid process at all. He says : " The clavicle and spine of the scapula were 
uninjured ; the shoulder was thrown forward so much as to give at first sight 
the appearance of a luxation forwards of the head of the humerus, but upon 
taking hold of the arm the motions of the articulation were found to be perfect, 
showing that the humerus had not left the glenoid cavity; the humerus too 
could be traced in its whole extent, and was not fractured ; upon rotating the 
arm or pushing backwards the shoulder, the trunk being firmly supported, cre- 
pitus was very evident, and the deformity could be made to disappear, but 
immediately that the force was dispensed with it returned. From the existence 
of the above symptoms the injury was judged to be fracture of the neck of the 
scapula." Now the data here given are not sufficient to make a precise diag- 
nosis. As the clavicle and spine were uninjured we may conjecture, if we 
are right in what we have said above, from the fact that the deformity was 
considerable, that the fracture of the scapula did not extend inside of the 
coracoid process, and that it was left attached to the body of the scapula, but 
that is as far as we can go. It may be said that in all these cases the treatment 
must be the same, and that so far as the good of the patient is concerned a 
precise diagnosis is unimportant. The greater the experience and the more 
enlightened the judgment, however, the less apt is this assertion to be made. 
The words of the celebrated secretary of the Royal Academy of Surgery, Louis, 
prefixed by Smith to his valuable memoir on the diagnosis and pathology of 
fractures of the neck of the femur, cannot be held too much in remembrance ; 
we thus translate : "Among all the parts of the art of surgery the science of 
diagnosis holds the first rank, and it is the most useful, and the most difficult of 
them all; without an exact and precise diagnosis, theory is almost always 
faulty, and practice often incorrect." 

The important peculiarities related by Prof. Dugas, as existing in the two 
cases he records, and which he is not aware to have ever been mentioned by any 
author in connection with this accident, are lesions of the axillary artery and 
nerves, producing an absence of pulsation in the arteries of the limb, and 
paralysis of its muscles. These lesions, it is true, are exceedingly rare, par- 
ticularly that of the rupture of the axillary artery, but it is wrong to' suppose 
that they have never been noticed. Nelaton [Path. Chirurg., torn. ii. p. 368) 
records a case which occurred in his own practice, where in a luxation under 
the glenoid cavity, the two internal tunics were torn to a very limited extent; 
a false consecutive aneurism rapidly developed itself, and three months later 
he was forced to have recourse to ligature of the subclavian, which he performed 
above the clavicle ; the disease had already made such alarming progress, that 
the aneurismal sac, in spite of the ligature, opened and destroyed the patient. 
Malgaigne (torn. ii. p. 197) gives a case observed by Prof. A. Berard, of sub- 
coracoid luxation, where there was no pulse after the accident; the vessels re- 
mained obliterated, gangrene invaded several of the fingers, and the patient 
died. At the post-mortem examination, the two internal tunics of the axillary 
artery were found torn in their whole circumference, and the cellular tunic was 
lengthened as a glass tube softened by heat and drawn out. 

Sudden paralysis, after dislocation of the shoulder, is more frequent than the 
absence of arterial pulsation ; indeed, it has been described so often that we 
are surprised at Professor Dugas's assertion that it has never been noticed by 
surgeons. It can be said to have always excited their attention. The muscle 
usually paralyzed is the deltoid, which, as is well known; is supplied by the 
circumflex nerve ; hence, this nerve was supposed to be lacerated by the acci- 
dent forcing the head of the humerus from the scapula. But at times the 
paralysis is much more extensive, and affects all the muscles of the arm, as in 
the cases reported by Professor Dugas. We have seen a case ourselves, and 
which we have reported elsewhere, in which the biceps, the brachialis anticus, 
the coraco-brachialis, the supra-spinatus, the infra-spinatus, the serratus mag- 
nus, and the supinator longus, were all paralyzed. In this patient, the paralysis 
followed immediately a fall upon the shoulder, and there was no luxation of the 
head of the humerus. Compression of the brachial plexus by the luxated head 



226 



Bibliographical Notices. 



[Jan. 



is usually assigned as the cause of this affection, but such compression has 
never been determined in autopsies; and, so far as sub-coracoid and intra-cora- 
coid luxations are concerned, it may be considered as impossible. Again, in 
some cases, as in the one we just mentioned, the paralysis has followed a fall 
upon the shoulder, without the head of the bone having left the glenoid cavity. 
Could not the brachial plexus be contused by something else than the head of 
the humerus ? It can very readily happen, as Nelaton first assured himself by 
experiments upon the dead body, by a force pushing the clavicle against the 
first rib, as in a fall upon the shoulder, by which the clavicle is carried 
inwards and backwards. And, what it is important to notice, the axillary or 
circumflex nerve is found at the points the most exposed to pressure. By 
making a dissection of the parts, or even by glancing at a well executed plate, 
any one can easily satisfy himself of this. This is a very interesting subject, 
and one well worthy of study; we have, however, already exhausted all the 
time at our disposal for the examination of Professor Dugas's paper. 

2. According to the examination of the history of the operation of ligature 
of the primitive carotid, made by Dr. "Wood, it appears, though it certainly was 
performed before, that the first operation in which the date is fixed with exact- 
ness, and the history of the case given with accuracy, is one in which it was 
tied for hemorrhage, following an attempt at suicide, on board a British vessel 
of war, the Tonnant, on the 9th of October, 1803, by Dr. Coley. Eighteen 
days afterwards, it was tied by Dr. Cogswell, of Hartford, Ct., in the removal 
of a tumour of the neck. These cases were not reported, however, for years 
afterwards ; the first appeared for the first time in the Med.-Chir. Journal for 
January, 1807, the other in the New England Journ. of Med. and Surg, for Octo- 
ber, 1824. The celebrated operation of Cooper was performed on the first of 
November, 1805 ; and it is very properly the first paper printed in the Medico- 
CMrurgical Transactions. It may be judged, therefore, from the recentness of 
these dates, that there are many points connected with this operation not yet 
decided, and Dr. Wood has done well to place on record his experience in this 
operation, and to add to it all the other unpublished cases of the city of New 
York, in order that they may be examined by those interested in the matter. 

The following is the summary prepared by Dr. Wood himself, which includes, 
of course, only the reported cases: — 

" The common carotid was ligatured for the following causes : — 

Hemorrhage. — Whole number, nine ; of which six recovered, and three died. 

Cause of Death. — Two became hemiplegic ; one, a few hours after the ope- 
ration, dying comatose, no autopsy; the other, on the second day, also dying 
comatose, and revealing, on post-mortem examination, softening of the brain 
and inflammation of the pleura. One died on the eleventh day, and, on exami- 
nation, was found to have had pericarditis, with collections of pus in apex of 
lung, and liver. 

Malignant Disease of Head or Face. — Whole number, seventeen ; of which 
four resulted in the apparent cause of the original disease ; ten were decidedly 
benefited, growth of the tumour being for a time arrested; two died; one not 
noted. 

Cause of Death. — In one, hemiplegia supervened twenty-four hours after 
operation, and death occurred in sixty hours ; autopsy revealed extensive 
softening of the brain ; in the second case, death occurred three or four days 
after the operation, from exhaustion. 

Aneurism by Anastomosis. — AVhole number, ten ; of which four were cured ; 
one died ; five were benefited. 

Cause of Death. — In the one fatal case, phlebitis was found to have existed, 
pus found in cavity of deep jugular vein. 

Aneurism of Branches of Carotid. — Whole number, four; all recovered. 

Epilepsy. — Whole number, two ; both benefited but not cured. 

Removal of Tumour. — Whole number, seven ; all recovered. 

Secondary Hemorrhage occurred in five instances, slightly in two, and severely 
in three ; all recovered, the hemorrhage being controlled by pressure. 

Date of Separation of Ligature was noted in twenty-four cases; maximum 



1858.] 



American Surgical Tracts. 



227 



period, thirty-one days: minimum, nine days: average, fourteen days and 
twenty-one twenty-fourths." 

Of these forty-eight cases, as is seen, six were fatal ; and of these six, three, 
or one-half of the whole number, were fatal from the direct action of the ligature 
upon the nutrition of the brain. Out of nine cases operated upon for hemor- 
rhage two died from this cause, and out of seventeen operated upon for malig- 
nant disease of the face or head, one. According to the important statistics of 
Dr. Norris, published in the XlVth vol. of this journal (1847), serious symptoms 
of cerebral disorder showed themselves 12 times in 38 ligatures of the primitive 
carotid practised for aneurism, or in about 32 per cent. ; in traumatic hemor- 
rhage, 8 times in 30, or less than 27 per cent. ; and in erectile tumours 8 times 
in 42, or 19 per cent. These proportions do not agree with those found to exist 
in the cases given by Dr. Wood in different affections. This goes to support 
what Broca says [Des AnSvrysmes, Paris, 1856, page 505), that neither the disease 
for which the ligature is practised, nor the age, sex, or constitution of the 
patient, in a word, none of the conditions which the surgeon can detect or 
foresee, explain the occurrence of these cerebral symptoms, which seem to 
depend chiefly upon the state of the anastomoses, peculiar to the individual. 

Cooper's first operation was followed by paralysis of the leg and arm of the 
opposite side, of which the patient had nearly recovered when she died of in- 
flammation of the sac and the surrounding parts. The first fears excited by this 
were soon dissipated, but from one excess surgeons went to another, and many 
authors said that the ligature of one primitive carotid could never seriously com- 
promise the cerebral functions. It is now, however, an unquestionable fact, that 
it not only can, but does ; in Dr. Wood's cases, as was noticed, one-half of the 
deaths had this for their cause. If the disease, therefore, be one of the exterior 
arteries of the head, or one of parts supplied by them with blood, it seems to us 
that the external instead of the primitive carotid should be tied. The operation 
itself would be one of greater difficulty, but that should not be taken into the 
account. There is reason to fear the influence of the neighbouring branches, 
all of them large, given off by this artery, so soon after the bifurcation of the 
carotid, and this is the only legitimate objection we can think of to the opera- 
tion. Broca, in the work above cited, says, that he has seen the external carotid 
tied with success in a case of traumatic aneurism of the parotid region. The 
operator was Mr. Adolph Richard. 

In the remarks communicated by Dr. Valentine Mott, the most remarkable 
point is, that he has ligated the common carotid artery forty-four times. 

3. The Thesis of Dr. Johnson was submitted to the public examination of the 
Trustees and Faculty of Medicine of the College of Physicians and Surgeons 
of the University of the State of New York, for the Degree of Doctor in Medi- 
cine. The question, whether or no intra-capsular fractures of the neck of the 
femur unite by bone is herein discussed, and the negative conclusion is arrived 
at. The author thus sums up his argument : "1. It is. absolutely impossible 
to form a certain and unmistakable diagnosis of all these fractures during the 
life of the patient. 2. That the probabilities are all against union by bone, 
from lack of nourishment to the fractured part of the head, from impossibility 
of perfect rest, and from synovitis. 3. The argument from the analogy of frac- 
tures of the patella, olecranon, etc., is an argument against, instead of for 
osseous union. 4. Cases where every circumstance was favourable to union, 
if any fractures of this kind could unite, yet which failed to unite. 5. The 
cases given to prove this union not having proved it." 

Many bitter controversies would never have occurred in the world, if it 
had been rightly borne in mind that opinions may be discussed but not facts; 
facts are determined. There are thousands of arguments of the most plausible 
character in favour of the opinion that oxygen and hydrogen do not form water; 
but this does not invalidate the fact in the least. The fact is determined, and 
there is an end of the controversy. Supposing that the first four heads of the 
above summing up were proven, which we are by no means willing to grant, it 
would only result that the opinion was one to be discussed, that bony union 
in these cases was improbable. As to the 5th heading, that the cases given to 



228 



Bibliographical Notices. 



[Jan. 



prove this union have not proved it; it gives evidence of far more credulity to 
believe that all those who bear testimony to the fact of osseous consolidation 
have been deceived, than to believe it true, were it a thousand times more im- 
probable than it is. 

The essential cause of a frequent failure in bony consolidation, in intra- 
capsular fractures of the neck of the femur, is owing to a want of proper co- 
aptation, due chiefly to the extreme mobility of the superior fragment. But 
the most important of all causes preventing it must be imputed, we believe, less 
to the fracture itself than to the apparatus employed. Sir Astley Cooper, con- 
vinced that it was impossible in this variety of fracture, after a few days of rest, 
permitted his patients to get up and walk with crutches ; is it surprising that 
consolidation did not occur, and that the synovial membrane became inflamed ? 

We have seen ourselves a case of bony union in an old patient who died of 
cancer, and where no apparatus had been applied. The case is reported else- 
where, but we will give it here. 

An old woman died in the wards of M. Nelaton, in November, 1853, with ascites 
from cancer of the liver. She had entered five months before, after a fall upon 
the hip, with signs of a fracture of the neck of the femur, and a fracture within 
the capsule. No apparatus whatever had been applied to the limb. At the 
post-mortem examination, bony union was found to exist between the fragments. 
There was a difference in length in the two thigh-bones of two-fifths of an inch ; 
the fractured bone being shortened. The fracture was intra-eapsular, com- 
pletely so in all its extent ; it followed the edge of the calotte articulaire. The 
displacement was this : the body of the femur had undergone rotation, the 
anterior and internal portion had been carried forwards ; posteriorly, the neck 
was driven into the head of the bone, while anteriorly, the fragments were 
separated. The specimen was afterwards divided by a saw, so. that a true bony 
union between the fragments was made most evident. M. Nelaton will answer 
for the truth of this. We see from this case that when the fragments are held 
in contact by nature, they unite under very unfavorable circumstances ; and 
we should, therefore, be encouraged to attempt by art to do the same. 

The article by Professor Mussey, on Fractures of the Neck of the Thigli-hone, 
published in the April number (1857), of this journal, contains testimony so 
strong in favour of the osseous consolidation of such fractures, when intracap- 
sular, that it is impossible to question it reasonably. 

It seems to us that the question of the bony consolidation of intra-capsular 
fractures of the femur is entirely settled by the facts brought forward ; it is one 
of the veracity of the authors who have published examples of it. As Smith 
says in his memoir on this subject, " If we believe these authors to have been 
competent judges, that they have had opportunities of acquiring correct in- 
formation, and that they have not been superficial observers, we must either 
believe their statements, or expose ourselves to the charge of scepticism, and 
render it obvious that our judgment has been so warped by theory and pre- 
conceived ideas, that no amount of evidence would be sufficient to alter our 
opinions." P. 56. There was a time in science when the weight of authority 
sometimes prevented the acceptation of facts, now very often facts will not be 
received, no matter upon what authority. It is remarkable at the present time, 
how many young men there are in this country and abroad, who work at the 
great storehouses of knowledge as if they were Augean stables to be cleaned, 
and theirs was the Herculean arm to accomplish the labour. 

4. The Surgical cases of Dr. Gay, in themselves very interesting, are related 
in so able and so satisfactory a manner that it is really delightful to read them. 
Three well executed plates, each containing two figures, accompany the text, 
and assist in enabling the reader to thoroughly understand the state of the parts 
affected in the first two cases, which are perhaps those of the greatest interest. 

The cases are four in number. The first is one of large fatty tumour of the 
left thigh, the weight of the tumour after removal being within a fraction of six 
pounds. The diagnosis of the affection is particularly dwelt upon, as it is in 
all the cases. The second is one of cystic tumour of the forearm, which was 
operated upon as fibro-plastic, but found to be a cyst, with thick, tough walls, 



1858.J 



American Surgical Tracts. 



229 



adherent to the surrounding tissues, and containing in its cavity a free de- 
tached scale-like piece of bone. The third is one of encephaloid disease of the 
thigh, in which a correct diagnosis was almost, if not quite, impossible. The 
fourth, one of venous erectile tumour of the forearm, in which the diagnosis, 
here and abroad, had always been lipoma. 

The reading of the histories of these four cases is a source of both pleasure 
and of profit to one fond of surgery. 

5. The extraordinary operation performed by Dr. Cooper, was reported to the 
San Francisco County Medico-Chirurgical Association, and published, by the 
authority of the association, by a committee appointed for that purpose. It is 
extraordinary even for California, that land of enormities of every description. 

A young man, 25 years of age, named B. T. Beal, by the premature bursting 
of an old gun, was wounded by a slug of iron, which had been driven into 
one end, as a temporary breech-pin. It entered the left side, fracturing the 
sixth rib, and remained in the chest until it was extracted 74 days afterwards. 
The patient at that time was in a state of extreme prostration ; purulent matter 
was discharging through the opening made by the slug ; the left lung had lost 
its function, and the symptoms of suffocation were most alarming. It was in 
this condition that he was first seen by Dr. Cooper, and the operation was 
performed without any delay. 

A T-shaped incision was made in the situation of the original wound, the 
soft parts were reflected so as to expose the ribs, and an effort was made, by 
using a probe to find the breech-pin. Not succeeding, portions of the 5th, 6th, 
and 7th ribs were removed, so as to make ample room to afford every facility 
for the further prosecution of the search ; in doing this a discharge occurred of 
about ten ounces of a fluid resembling venous blood, contained in a cyst con- 
nected with a portion of the sixth rib, which was carious ; this was followed, soon 
afterwards, on breaking up some attachments with the finger, by another dis- 
charge of at least two quarts of purulent matter. The pleura was very much 
thickened, and contained several large holes through which the pulsations of the 
heart could be distinctly seen. During the whole of this time the patient appeared 
to be rapidly sinking ; brandy was given freely, and after a time chloroform 
was administered. The thoracic cavity was explored for at least three-quarters 
of an hour with a sound, before anything like a metallic touch could be re- 
cognized, which finally was accomplished by passing the instrument between 
the descending aorta and the apex of the heart. The pulsations of the heart 
against the instrument were so strong that it was very difficult to settle the 
matter definitely, but it was at last evident that the locality of the iron was 
found. The sound was held against it, until a pair of long lithotomy forceps 
was thereby conducted to the spot and the breech-pin seized and extracted. 
The forceps could not follow the sound and be expanded sufficiently to seize 
the metal without lifting the apex of the heart considerably out of its natural 
position. 

The patient recovered rapidly after the operation, and at the expiration of a 
few months seems to have been as well as before the accident, although the 
left breast remained somewhat sunken. 

In the remarks made by the operator upon the case, the recovery of the pa- 
tient is attributed to "his great cheerfulness, good constitution, and to the 
effects of our unparalleled climate, in which it appears nearly impossible for 
a patient to die with almost any ordinary degree of injury, provided a rea- 
sonable share of attention is afterwards given him." A serious objection to 
the climate, however, is the frequent occurrence of these terrible injuries, and 
we fear that it is an objection not likely soon to disappear. W. F. A. 



230 



Blhliograpliical Notices. 



[Jan. 



Art. XX. — A Collection of Remarkable Cases in Surgery. By Paul F. Eve, 
M. D., Professor of Surgery in the Medical Department of the University of 
Nashville. Philadelphia : J. B. Lippincott & Co., 1857. 8vo. pp. 858, in- 
cluding a copious index. 

This work is simply a "book of curiosities in surgery. As such, it will, in 
spite of its scientific claims, almost inevitably drift into the company of the 
numerous " Extraordinary" biographies, " Harrowing Adventures," and other 
like sensation-stirring popularities. 

In these days of exuberant journalizing, when some periodical is within the 
reach of every respectable practitioner, and when all the rare and horrid cases 
are printed and reprinted with dreary faithfulness and uniformity, we cannot 
perceive the advantage of publishing, in an expensive octavo of over eight hun- 
dred crowded pages, such an omnium gatherum of modern instances and thrice- 
told tales, however curious in themselves or appropriately strung together. 

With all due deference to the merits of the compilation, and of its supple- 
mentary matter generally, we are inclined to regard the index, which occupies 
some thirty-four pages, as the most useful portion of the book. This index 
needs only the references to the original authorities, given with each case, to be 
of more actual scientific value than all the rest of the work ; since it would then 
point out to us, in a few alphabetical columns, the sources of a large number of 
observations which are here to be traced only by searching through the many 
wearisome pages of small type, upon which they are spread out according to 
the fancy of the collector. 

Dr. E. informs us, in his introduction, that he " has been studious to do injus- 
tice to no one ;" and yet he "has taken the liberty, occasionally, to abbreviate 
articles; in some instances to give them a more striking and appropriate title ; 
and now and then to add a few brief comments." Whatever ideas the authors 
of the various papers, which he has thus dished up after his own fashion, may 
have of his mode of doing them "no injustice," we feel bound as a reader, and 
still more as a reviewer, to protest decidedly against all pretensions to scientific 
value in the reports of cases as he presents them. There are no distinctive 
marks by which can be recognized either the alterations or the comments and 
headings above alluded to ; and hence we have nothing to prevent us, in quot- 
ing or reading Dr. Eve's versions, from misrepresenting or misunderstanding 
the original reporters. None, therefore, but those who are content to study 
the cases through the compiler's spectacles will be likely to resort to his pages 
except to gratify curiosity, or to take comfort in the "one practical lesson," 
which, as he truly tells us, is suggested, " not to be easily discouraged in 
desperate surgical cases." 

According to the introduction, Dr. E/s object " has been merely to gather for 
preservation the valuable material now existing mostly in a perishable form ; 
to collect the important and instructive cases from our journals, &c, and ar- 
range them for future reference." In prosecuting this peculiar enterprise, he 
has grouped together an array of narratives and commentaries, good, bad and 
indifferent, which is a marvel in itself; and, along with many that were long 
since sufficiently embalmed, he has certainly rescued, and brought out to some 
extent, many notable records which might otherwise have been generally over- 
looked. The presence of these very cases, in the midst of others of vastly less 
account, or out of place, in such a book, renders it especially provoking, not 
only that they should be encumbered with such a mass of other matter, but 
that we have no guarantee that any one of them is given in its strictly original 
form. 

No cases, we are told, " have been admitted into the collection but such as 
are strictly authentic ; as it has been our aim to reject all of a doubtful cha- 
racter." A very extended and careful examination inclines us to believe that 
this claim of authenticity is generally well sustained. Some of the stories, 
however, are too manifestly apocryphal to be accepted under any circum- 



1858.] Eve, A Collection of Remarkable Cases in Surgery. 231 



stances ; while others are given under authority which would scarcely be ad- 
mitted as conclusive in a court of law. The first case of Sect. II., for example, 
although quoted, with preliminary comments, from the Boston Med. and Surg. 
Journal of 1847, has no authority for its accuracy but that of a country news- 
paper. It is quoted as a remarkably striking demonstration of the "great 
elasticity of the skull in a child," and is in the following words : " A few days 
since," says the Amherst Express, " a son of Mr. Dudly, of Shutesbury, Mass., 
about five years old, accidentally fell from a cart containing about twelve hun- 
dred pounds weight, which passed directly over his head. He received no 
apparent injury except a slight bruise near the ear made by the wheel." This 
instance of cranial "elasticity" is so well matched by another, at least as cre- 
dible, that we venture to reproduce it here, as available for a second edition, 
without any other voucher than the authority of the Calaveras (Cal.) Chronicle. 
This paper states "that two 'colored gemmen' in that place, who had quar- 
relled about ' a lady/ met in mortal combat. After an exchange of shots, the 
sheriff arrested the parties and carried them to jail, when a pistol bullet was 
found flattened out and lodged in the wool of one of the combatants, who was 
quite unaware of having been touched." We are willing to allow something 
for the " wool" in our case, but must nevertheless insist that it is quite as 
much entitled to the honour of a place in Sect. II. as the adventure of Master 
Dudly. It is strange that none of the parties concerned in circulating the Am- 
herst story appears to have suspected the possibility of a mistake. The nature of 
the accident would suggest itself at once to most hospital surgeons as a matter 
of not unfrequent experience. We can recollect three different similarly mar- 
vellous escapes, occurring under our observation within the last five years. In 
the first case, a child of seven years was apparently run over in a paved street 
by a mail wagon weighing at least a ton; although one of the massive hind 
wheels was seen by several persons to pass directly across his right thigh, the 
only perceptible injury resulting was a transverse fracture of the femur and 
slight abrasion of the skin, without material contusion of the soft parts, from 
which he recovered in the usual time. The pavement was a rough one of large 
cobble stones, and the child, if really run over, was doubtless saved by the 
bouncing of the wheel from one stone to another. The second case was that 
of a youth of seventeen years, who, while dragging by the rope of a fire engine, 
was overturned in a bed of snow ; the wheel of the heavy vehicle immediately 
passed across his left thigh in such a manner as to produce a simple fracture 
without other injury. The third case was that of a carter who fell into a mud 
puddle in such a way that his cart, with a load of bricks weighing at least two 
tons, passed with one of the wheels diagonally across his arm above the elbow- 
joint. A compound fracture was the result ; but, in consequence of the yield- 
ing of the bed of mud beneath it at the time, the limb was not so much injured 
as to require amputation. The means of escape from more serious mischief 
to the parts apparently exposed to certain destruction were obvious enough 
in these latter two cases ; but the good fortune of the little fellow in the first 
of the three, however evident, was surely not more explicable than that of the 
child in Massachusetts. 

With regard to the arrangement we may say, in a few words, that there are 
ten chapters, each of which is divided into sections. Of these sections there 
are some seventy-three in all. The cases, instead of being numbered in regu- 
lar order of succession throughout the book, are numbered only in each sec- 
tion ; so that it is impossible to ascertain the whole number without a needless 
cost of time- and labour in the computation. 

Each chapter is devoted to a particular anatomical region of the body, and 
the sections to different portions of these regions ; the lengths of chapters and 
sections being intended to indicate " the supposed importance of the respective 
regions which they represent." Thus we have chapters on the Head, Spinal 
Column, Face, Neck, Chest, Abdomen, Pelvis, Genito-Urinary Organs, and the 
Extremities, each with its sections devoted to minor parts ; lastly, our compiler 
is obliged to stow all unarrangeable matter, as usual, in a miscellaneous chap- 
ter, which is the longest and most remarkable in the book. 

Bulky and full as this surgical scrap-book is, we feel that it has occupied 



232 



Bibliographical Notices. 



[Jan. 



quite as much attention as can be afforded to it in a passing notice. With the 
best disposition towards its sponsor, and respect for the zeal and talents which 
have won him ample distinction in other more congenial fields, we trust that 
his next experiment in authorship will yield him more undivided honours, and 
that he may then wield the pen as freely as on this occasion he has used the 
scissors. 

It is due to the publisher, and particularly to the local editor, Dr. W. Go- 
brecht, to say that the book is accurately printed and respectably got up ; and 
that the index is especially meritorious as a characteristic and successful spe- 
cimen of editorial labour. E. H. 



Art. XXI. — Medical Lexicon — A Dictionary of Medical Science, containing a 
Concise Explanation of the Various Subjects and Terms of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obste- 
trics, Medical Jurisprudence, Dentistry, etc. ; Notices of Climate, and of Mineral 
Waters ; Formulas for Officinal, Empirical, and Dietetic Preparations, etc., 
with French and other Synonymes. By Eobley Dunglison, M. D., LL. D., 
Professor of the Institutes of Medicine, etc., in the Jefferson Medical College 
of Philadelphia. Revised and very greatly enlarged. 8vo. pp. 992. Phila- 
delphia, 1857 : Blanchard & Lea. 

A dictionary, if it but comprise a simple vocabulary of all the various terms 
that occur in the different branches, direct and collateral, of medical science, 
with a clear and concise definition of the sense in which they are employed — a 
mere terminological lexicon — is a work which every medical man will find a 
valuable appendage to his reading table. Some work of the kind is, in fact, in- 
dispensable to student and practitioner, more especially now, when the progress 
of discovery and of improvement in every department of medicine is such as 
to require the constant adoption of new terms to express the many and varied 
additions that are constantly being added to our stock of professional knowledge. 
If such a lexicon is confessedly a valuable and frequent book of reference alike 
to the physician and student, how much more so must be a dictionary, in which 
they are presented with not simply a definition, but a concise explanation of all 
the subjects and terms in every department of medicine, and in those sciences 
that are directly or indirectly connected with it, with notices also of climate and 
of mineral springs, formulse for officinal, empirical, and dietetic preparations, 
etc., of everything, in short, upon which they may at any time demand prompt 
general information, without the delay or trouble of consulting other works. 
The explanations given being, at the same time, expressed in a clear and defi- 
nite manner, and in strict accordance with the views and usages of the latest 
and best authorities. It is precisely such a dictionary — full, copious, and accu- 
rate — that is presented to the profession by Dr. Dunglison, in the fifteenth edi- 
tion of his medical lexicon now before us. 

Complete and comprehensive as the work appeared to be in the preceding 
edition, the untiring industry and research of the author have enabled him to 
add to the present, six thousand additional subjects and terms. Many of these, 
he informs us, have been introduced into medical terminology in consequence 
of the progress of the science, whilst others had escaped the author in the pre- 
vious editions. 

While we cheerfully concede all credit to Dr. Dunglison for the production 
of a medical dictionary, better adapted for the wants of the profession than any 
other with whieh we are acquainted, and of a character which places it far 
above comparison and competition ; some praise we think is due, likewise, to 
the publishers, who, by their liberality of expenditure in its passage through 
the press, have enabled the author to arrange all his additions and improve- 
ments in their appropriate places in the body of the work, instead of adding 
them, as an appendix, to the preceding edition ; thus saving to those who have 
occasion to consult the dictionary, the trouble and vexation of a double refer- 



1858.] 



Brodhurst, Nature and Treatment of Club-foot. 



233 



ence ; and this has been done, too, without materially increasing the bulk of 
the volume, by the employment of a small but very clear type, cast expressly 
for the work. D. F. C. 



Art. XXII. — On tlie Nature and Treatment of Club foot and Analogous Distor- 
tions, involving the Tibio-tarsal Articulation. By Bernard E. Brodhtjrst, 
Assistant Surgeon to the Royal Orthopaedic Hospital, etc. etc. London : 
Churchill, 1856. 8vo. pp. 134. 

The introduction to the volume now before us is occupied with an historical 
retrospect of orthopaedic surgery; and we are presented by Mr. Brodhurst 
with an accurate account, for the first time in an English dress, of the earlier 
operations practised for the relief of club-foot. That club-foot and its analo- 
gous affections had been studied by the ancient physicians, is sufficiently proven 
by a perusal of the chapters in which Hippocrates has discussed the subject; 
in fact, the treatment by mechanical apparatus which he lays down, will answer 
sufficiently well, even at this day, for the cure of the simpler forms of varus. 
Subsequent to the time of Hippocrates, for a period of 2000 years, little im- 
provement was made in the treatment of this deformity, although we find fre- 
quent allusion to the complaint in the works of Pare, Severinus.- and Fabricius- 
ab-Aquapendente. In 1784, tenotomy was successfully practised for the first 
time by Thilenius, of Frankfort, for the cure of equino-varus. The next opera- 
tion of which we have mention, was that performed by Sartorius, in 1806 ; the 
result was not, however, favourable; indeed, we even wonder at the happy 
result in the preceding instance, when we learn that the method of operating 
adopted was by a large dissection with a free external wound. Subcutaneous 
tenotomy had not as yet been practised ; it was reserved for Delpech. to make 
this last and great improvement in the treatment of talipes. The rules which 
he laid down some few years later are, as our author states, " absolutely those 
which guide the surgeon at the present day." Stromeyer afterwards prac- 
tised Delpech's operation extensively, although, undoubtedly, the merit of the 
procedure is due to Delpech. 

In Chapter II., Mr. Brodhurst passes to the consideration of congenital talipes, 
and lays down the division of the various forms of the distortion. This portion 
of the work is well illustrated, and the description of the tissues at fault is drawn 
with exceeding clearness. The etiology of congenital talipes is next entered 
upon. The different opinions as to the cause of the affection may be classed 
as follows : — 

1st. Malformations and displacements of the tarsal bones. 

2dly. Affections of the muscular system. 

3dly. Malposition in utero. 

4thly. Disordered nervous influence. 

The first three causes assigned cannot, in the opinion of our author, be sub- 
stantiated by observation, for he adds, at p. 48, " It may be safely said that the 
tarsal bones are never primarily affected, but, being acted upon by the mus- 
cles, are twisted on their axes." * * * " The muscles are doubtless the 
agents through which the tarsal bones become rotated, but being themselves 
under the influence of the nervous system, other agency than that of the mus- 
cles and ligaments is involved in the production of congenital distortions." 
We are also told that the opinion of Cruveilhier, that malposition of the foetus 
in utero is the exciting cause, is equally untenable. With regard to the fourth 
and last cause mentioned above — viz., disordered nervous influence — Mr. Brod- 
hurst informs us that club-foot, and all other distortions, are most frequently 
met with in those foetuses in whom there is deficiency or marked change from 
the normal state of the brain and spinal cord. In the anencephalic monster, 
these deformities are most common. 

The causes of non-congenital talipes, which are next considered, are arranged 
by the author under the following heads — paralysis, spasm, inflammation, 



234 



Bibliographical Notices. 



[Jan. 



voluntary position, and debility. This chapter forms one of the most interest- 
ing in the volume, and is fully illustrated by clinical cases. With some remarks 
upon the structural pathology and degeneration of muscles, and the reunion of 
tendons, Mr. Brodhurst then passes to the most important topic, practically, 
connected with the deformity in question — viz., the treatment. To use his own 
words, " The treatment of talipes resolves itself into, first, the removal of dis- 
tortion and restoration to the normal position of the limb ; and, secondly, the 
restoration of function. ;; The operation of tenotomy, we are informed at page 
113, is only useful in the strictest sense to facilitate mechanical treatment; an 
opinion in which we most heartily concur. In the adult, especially, tenotomy 
alone does little or nothing towards the immediate reduction of the distortion. 
At the same time Mr. Brodhurst says, and in this point we do not altogether 
agree with him, that there are few cases in which extension alone is to be pre- 
ferred to tenotomy. Upon this topic, we would refer our readers to the admi- 
rable remarks of Dr. Little, which have recently appeared in the last numbers 
of the London Lancet. 

The period at which, in cases of congenital talipes, the author prefers ope- 
rating, is from four to six weeks after birth, provided the infant be robust. The 
after treatment consists in the application of proper extending apparatus, and 
it is safest, according to the author, not to commence the extension of the heel 
until the process of reunion shall have begun. If much elongation of the 
achilles tendon be desired, it must be obtained during the second and third 
week after the section. 

We cannot bring our hasty notice of Mr. Brodhurst's monograph to a close, 
without expressing our satisfaction with the volume. We have been forcibly 
struck during its perusal with the pains-taking care of the author to establish 
in each case a correct diagnosis of the deformity in question, and we entirely 
agree with him in the following deprecation of unnecessary and hasty operative 
interference: " Much obloquy has been cast on orthopaedy in consequence of 
the abuse of tenotomy. The senseless division of tendons on every possible 
occasion, and without reference to the cause of distortion, has occasioned infi- 
nite injury to the cause of orthopaedy ; congenital and non-congenital affections 
being similarly treated by those who, through ignorance of the pathological 
condition of parts directly or indirectly involved, are unable to form an accu- 
rate diagnosis, to distinguish between the various forms of non-congenital 
distortions, and to decide between cases fitted and unfitted for the section of 
tendons/' J. H. B. 



Art. XXIII. — Pathological and Surgical Observations : Including a short Course 
of Lectures delivered at the Lock Hospital, and an Essay on the Surgical Treat- 
ment of Hemorrhoidal Tumours. By Henrv Lee, F. R. C. S.. Surgeon to the 
Lock Hospital, Assistant Surgeon to King's College Hospital, etc. London : 
Churchill, 1854. 8vo. pp. 232. 

The volume before us comprises a series of surgical papers from the pen of 
Mr. H. Lee, of London, Surgeon to the Lock Hospital and Assistant Surgeon 
to King's College Hospital. Some of these papers have especial value from the 
fact that they are founded upon direct observation, and also because the results 
arrived at differ in many respects from opinions hitherto generally received. 
A subject which seems to have engaged the attention of Mr. Lee more particu- 
larly, and one which he has most patiently examined, is a study of the " Causes, 
Consequences, and Treatment of Inflammation of the Veins." This article is 
a continuation of a dissertation to which the Jacksonian prize was awarded in 
1850. 

The main conclusions arrived at in this last publication are, as stated by the 
author: "1st. That inflammation, both of the veins and capillary vessels, usually 
depends upon irritation, communicated to them through their contents. 2dly. 
That pus is capable of producing such irritation, when detained in contact with 



1858.] Lee, Pathological and Surgical Observations. 235 

the lining membrane of the veins; but that it maybe conveyed along their 
channels, without leaving any trace of its passage. 3dly. That pus, under 
ordinary circumstances, cannot circulate in living vessels, in consequence of its 
power of determining the coagulation of the first portions of the blood with 
which it is brought in contact. 4thly. That when pus is carried along a vein 
it is in consequence either of the disturbance of the coagulum which has first 
detained it, or of the blood having, in some measure, lost its natural power of 
coagulation." 

Mr. Lee does not, in his present paper, recapitulate the evidence upon which 
the foregoing propositions are based, but proceeds to a review of the labours 
of other physiologists upon the same subject, and to a still further illustration 
of his own conclusions. He advances a series of experiments, performed by him- 
self and others, and also a collection of clinical cases, which have led him to 
the belief that the injection of putrid substances into the blood does not, as is 
generally supposed, prevent coagulation from taking place, but that, on the 
contrary, such coagulation is induced and assisted. Of all foreign substances, 
none possess this power in so marked and rapid a degree as pus. It is to this 
fact the author attributes the formation of the large patches of congestion 
found in internal organs when pus has accidentally entered into the circula- 
tion; and to the more feeble influence of putrid fluids, or of mercury, the de- 
velopment of patches of less size. 

From the physiological analysis of these affections, Mr. Lee deduces two 
principal indications : 1st. That in phlebitis there generally is a twofold dis- 
ease — viz., a local inflammation and a constitutional infection — hence the treat- 
ment to be pursued should be local depletion, whilst at the same time tonic con- 
stitutional remedies should be made use of. 2dly. Direct experimentation has 
taught him, that when a putrid element has been introduced into the blood, 
the mucous membranes of the intestines and liver are the principal channels 
by means of which the elimination of the morbid matter is attempted. 

In an article at page 95 upon the deposition of fibrin from the lining mem- 
brane of the veins, Mr. Lee seems disposed to reject the views generally held 
by English pathologists, and which have lately been adopted by Hasse, relative 
to the character of the serous tunic of the veins. He here questions the cor- 
rectness of the analogy which has been drawn between this membrane and the 
ordinary serous membranes of the body, in a pathological point of view. The* 
deposits of lymph found in veins whose walls have become indurated, in true 
cases of phlebitis, result, in the opinion of the author, from the previous coagu- 
lation of the blood, and he believes that the visible appearances of inflammation 
extend to the walls of the vein and not from them ; in other words, that they 
are secondary to the formation of the clot, and that they do not precede it. A 
repetition of the experiments of M. Gendrin, by the application of a double liga- 
ture upon the jugular vein, and by observation of the internal processes taking 
place, have led him to conclusions differing from those of the last-named ob- 
server, and which go to substantiate his opinions as already expressed. Thus 
he says (p. 99): "The principal conclusion to be drawn from the preceding 
experiment and observations is, that the analogy which has been supposed to 
exist between the lining membrane of bloodvessels and the closed serous 
cavities of the body, cannot be maintained with regard to their morbid pro- 
cesses ; and, consequently, that the mode of treating inflamed veins which has 
been based upon the supposed resemblance, is not founded upon sound physio- 
logical principles. Another point of secondary importance, but by no means 
devoid of interest, is the power which the blood is shown to possess of separat- 
ing directly from itself a fibro-albuminous element, without the intervention of 
any membrane, and independent of any inflamed surface." * ' * * " That 
the changes in the blood which immediately precede such an action may be 
caused by the admixture of vitiated secretions — that the deposit, when formed, 
is capable of undergoing various changes, which issue in the formation of a. 
purulent-looking fluid, and is capable during these changes of communicating 
irritation to surrounding parts." 

The system of experimentation practised by Mr. Lee is interesting in the 
extreme ; whether or not, however, its results will be borne out by future in- 



236 



Bibliographical Notices. 



[Jan. 



vestigation, it is impossible for us to say. In the mean time, we cordially re- 
commend the perusal of these papers to all of those who may be interested in 
the study of the diseases of the venous system. J. H. B. 



Art. XXIV.— The Practice of Surgery. . By James Miller, F. R. S. E., F. R. C. 
S. E., Professor of Surgery in the University of Edinburgh, etc. etc. Revised 
by the American Editor. Fourth American from the last Edinburgh edition. 
Illustrated by 364 engravings on wood. Philadelphia: Blanchard & Lea, 
1857. 8vo. pp. 682. 

"We have been so often called upon to express our approbation of Professor 
Miller's admirable surgical writings, that we feel that comment at the present 
moment is unnecessary. Indeed, the increasing demand which has necessitated 
a fresh edition of his Practice of Surgery, affords in itself ample testimony to 
the high position which his works occupy in the estimation of the surgeons of 
this country. 

The volume before us is the fourth American reprint from the third and last 
Edinburgh edition. The supervision of the work, as it has passed through the 
press in this city, has been confided to the care of one of our most able surgical 
writers, who has, with characteristic good judgment, presented the volume to 
the medical public almost entirely devoid of cisatlailtic annotations. In reality, 
Professor Miller's Practice of Surgery makes its appearance before us this time 
more nearly in the condition in which it left the author's table than it has ever 
done before. W e are glad that such is the case. 

Most of the notes which have been added by the present editor, refer almost 
entirely to American surgery, and could not with propriety have been omitted 
from a volume intended as a guide to American students and practitioners. 
The admirable operations of Drs. Sims, of X. Y., and Bozeman, of Ala., for the 
relief of vesico-vaginal fistula, are fully described at page 565. The success of 
these operators in the treatment of this dreadful malady has been such as to 
lead us no longer to look upon the result of all surgical interference as so " dis- 
couraging" as Professor Miller is inclined to consider it. 

The puncture of the bladder through the symphysis pubis, as suggested by 
Dr. Brandes, of Jersey, and practised in this country by Dr. Leasure, of Pa., 1 
is also alluded to ; a proceeding which, it appears to us, may be resorted to 
with advantage in many instances of retention of urine, especially in those 
cases where the bladder retains its normal position. We also observe, at page 
630, a somewhat elaborate extract from the various papers of Dr. Reid, of Ro- 
chester, N.Y., relative to the reduction of luxations of the femur by manipula- 
tion alone without extension, a plan of treatment which is now generally and 
deservedly coming into vogue, and which has been attended with much success. 

Many additional illustrations have been introduced into this edition, and 
although some of them strike us as familiar, having done duty already on more 
than one occasion, yet certainly they enhance the value of Professor Miller's 
useful treatise ; and we doubt not that the present edition will prove as de- 
servedly successful as its predecessors. J. II. B. 



1 See this Journal for April, 1854, p. 403. 



1858.] 



237 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. Researches on the Histology of the Nervous System. — Prof. Jacubowitsch, 
a young Kussian physiologist, has been laboriously engaged, for the last four 
years, in the microscopical study of the nervous centres. His discoveries an ! d 
drawings have recently excited great attention in Paris, and have been most 
complimentarily noticed by M. Flourens at the Academy of Sciences. 

The following is the resume of a communication made by him to the Academy, 
drawn up by himself and M. Castelnau, the editor of the Moniteur des Hopitaux 

1. The cerebro-spinal system is composed of three descriptions of cells, which, 
while assuming the essential form of the animal cell in general, are distin- 
guished by the following special characteristics : 2. Axis-cylinders arise from 
the periphery of these cells, which by their number distinguish each species 
of cell, (a) In the first species, or multipolar cells, the number of axis- 
cylinders radiating from the periphery varies from three to eight, and is 
habitually three or four. The form of this cell is irregular (6) in the second 
species, or fusiform cells, the axis-cylinders are three in number, sometimes 
four, but never more. They assume the spindle form, and are much smaller 
than the multipolar cells, (c) In the third species, or bipolar cells, the axis- 
cylinders are but two in number. These cells are of an oval form, and in size 
are intermediate between the two other species. 3. (b) The multipolar cells 
are met with in the medulla spinalis, in the cerebellum, and in the corpon 
quadrigemina. It is remarkable that none are found in the medulla oblongata. 
In the medulla spinalis they are situated in the anterior cornua and in the giay 
substance. (6) The fusiform cells are found in the medidla spinalis and ob- 
longata, in the cerebellum, in the corpora quadrigemina, and in all parts of the 
cerebral hemispheres, which are almost entirely formed of them. In the me- 
dulla spinalis these cells are placed in the posterior cornua. (c) The bipolar 
cells are found in the medulla spinalis and oblongata, in the cerebellum, and in 
the corpora quadrigemina; but the cerebrum does not contain any. In the 
medulla spinalis they are principally found around the central canal. They 
are very abundant in the medidla oblongata, constituting its 'greatest portion. 
4. (a) The axis-cylinders proceeding from the multipolar cells form the nerves 
of motion ; and it is for this reason that the author terms these cells, cells of 
motion. (6) The axis-cylinders of the fusiform cells form the nerves of sen- 
sation, and the cells are termed cells of sensation, (c) The axis-cylinders of 
the bipolar cells are in relation with the grand sympathetic ; and the cells are 
termed ganglionary cells. 5. The same and different species of cells com- 
municate with each other as follows : [a) The cells of motion communicate 
from one side to the other by the anterior commissure, or rather this commis- 
sure is formed by the intercrossing in every direction of the axis-cylinders 
No. LXIX.— Jan. 1858. IS 



238 



Progress of the Medical Sciences. 



[Jan. 



which proceed from these cells. Those of the same side also communicate by 
the axis-cylinders, which proceed directly from one to the other. (6) The 
cells of sensation communicate from one side to the other by the posterior com- 
missure, or rather they constitute that commissure ; but they remain parallel 
to each other, and do not intercross. Those of the same side communicate 
directly. (c) The axis-cylinders of the ganglionary cells pass by either the 
anterior or the posterior commissure ; and thus communicate from one side to 
the other, like both the other species, Communications also take place between 
those of the same side. (d) Communications, moreover, take place between 
the different varieties of cells ; but the author has only met with them in the 
cerebellum and in the corpora quadrigemina, in which the three varieties of 
cells occur. 6. The different species of cells are not equally abundant in all 
the regions of the medulla spinalis. Thus in the cervical and lumbar regions 
the cells of motion predominate, while in the dorsal region those of sensation 
are most numerous. 7. The medulla oblongata is purely and simply a pro- 
longation of the medulla spinalis, a prolongation entirely formed of cells of 
sensation, containing in their centre a nucleus of ganglionary cells. 8. The 
cerebellum is formed of four elements, viz. (a) of three elements, constituting 
the white substance, and which are prolongations by means of the peduncles 
of the pyramidal bodies which furnish the elements of the cells of motion, of 
the restiform bodies which furnish the elements of sensation, and of the gan- 
glionary element which enters with each of the other two. (b) Besides these 
three elements, the periphery, or cortical substance of the cerebellum, is formed 
of characteristic pyriform cells peculiar to this organ. From these pyriform 
cells prolongations are sent to the surface of the orgun, forming a layer termed 
by the author the couche en baguettes. 9. The corpora quadrigemina, formed by 
the prolongations or the peduncles of the cerebellum, by the restiform bodies, 
and by the horseshoe shaped commissure, contain the three varieties of cells 
which they derive from these various origins. But this is the last point 
where these three varieties are found together. Above this, in the hemispheres, 
as already stated, the cells of sensation, of which the corpus callosum forms the 
commissure, are alone met with. 10. With the exception of the optic, the 
olfactory, the auditory, the vagus, the glossopharyngeal, and the hypoglossal 
nerves, which only consist of cells of sensation and ganglionary cells, all the 
nerves are formed of the three varieties of cells, with this difference among 
them, that the nerves of motion contain especially the cells of motion, and so 
on. 11. Besides the elements now described, the cerebro-spinal system con- 
tains a special connective tissue uniting the other elements, and which differs 
from the connective tissue of other organs by not containing any cells. It is, 
moreover, in infinitely small proportion as compared with the nervous tissue, 
and seems to play no other part than that of a bond of union. 12. These three 
categories of cells vary in different species of animals. They are smallest in 
size in man, and in general they are small in a proportionate degree to the 
intellectual development. The number of the nervous cells bears no propor- 
tion to the size of the brain. 

From this brief resume, M. de Castelnau observes, we are enabled to deduce 
some of the principal consequences of the facts upon which M. Jacubowitsch's 
researches are based. 

1. The three entirely distinct functions of the nervous system, motility, 
sensibility, and organic action, are not only exercised by three different orders 
of nerves; but, moreover, these orders of nerves take their origin in different 
central anatomical elements. 

2. The medulla spinalis, whence arise the general nerves, contains equally 
and naturally the three orders of elements ; but the brain, the organ of the 
intellect, contains but the elements of sensibility, and the nerves of the special 
senses are also made up of the same element, with which is united in small 
proportion only the ganglionary element. 

3. The element of sensibility is in different dimensions in man and animals, 
being larger in the former and smaller in the latter ; so that for even an equal 
cerebral mass the human brain is much richer in sensible elements than is 
that of animals. To go beyond this, and to determine the relative richness of 



1858.] 



Anatomy and Physiology. 



239 



each man, arid especially of each human race, does not seem to be impossible. 
Will it ever be accomplished? That is a question Ave must reserve for future 
solution, but still with a doubt accompanied by much hope. 

4. M. Jacubowitsch's researches scarcely promise less to the pathologist than 
to the physiologist. They have already shown that in affections of the nervous 
system, in which the most minute ordinai-y examination could detect no 
material lesion, such lesion was nevertheless considerable, since one or more 
of these orders of elements had become greatly altered in their form, or even 
had undergone destruction. This single result sufficiently indicates the bril- 
liant horizon that may be opening to the pathological anatomist. If it exhibits 
to us clearly but a small part of that which we now seem to have a glimpse of, 
M. Jacubowitsch will not have rendered less service to the practitioner than 
to the physiologist and the true philosopher.— i/cwiYeMr des Hopitanx, Sept. 8, 
1857. 

2. On the Structure of the Nervous Centres. — Prof. Lenhossek has communi- 
cated to the French Academy of Sciences an interesting memoir on this sub- 
ject, of which the following is an abstract: — 

" It results from my researches, 1st. That the central nervous system is 
composed of gray substance, of white substance, and of an intermediate sub- 
stance, termed the gelatinous substance of Rolando. 2. That the gray substance 
is formed of a general hyaline mass, having three kinds of nerve-cells: (a) 
Nerve-cells with all their attributes, generally diffused ; (b) Large nerve-cells 
with all their attributes, united into groups. These are seen in the motor 
columns, in the sensitive columns, and elsewhere, (c) Spherical-nerve cells 
with all their attributes, filled with a deep brown pigment. These form only 
the ferruginous substance, and the black substance of Soemmering. 3. That 
the white substance is formed of primary fibres, which terminate in the form 
of radiations in the different organs of the central nervous system. 4. That 
the so-called gelatinous substance is formed by the gray substance, which 
traverses, in the form of network, the fasciculi of the white substance. 5. 
That the gray substance has the following relations : (a) In the spinal marrow 
it constitutes four columns, two anterior motor and two posterior sensitive, 
united together by the gray commissure: (b) In the medulla oblongata these four 
columns change their relative position, the anterior columns becoming internal, 
and the posterior external. They preserve this juxtaposition throughout the 
extent of the rhomboidal sinus. Farther on, the motor columns are continued 
alone to the bottom of the third ventricle, terminating in the infundibulum. The 
sensitive columns, on the contrary, pass into the optic thalami and the corpora 
striata, (c) At the point where the juxtaposition of the four columns takes 
place, there the commissure disappears, and the median cldison of Vicq d'Azyr 
commences, this being formed by a prolongation of the gray substance. This 
cloison is continued through the entire length of the pons Varolii. 6. That in 
the spinal marrow the white substance of the one side is completely separated 
from that of the opposite side by the anterior and posterior longitudinal groove; 
and in the medulla oblongata and pons Varolii an analogous separation is pro- 
duced by the cloison of Vicq d'Azyr. 7. That at the point where the juxtapo- 
sition of the four columns of the gray substance takes place, the white sub- 
stance proceeds more and more forwards until the gray substance at last 
remains exposed in the rhomboidal sinus. 8. That the primary fibres of the 
roots of all the nerves arise in the gray substance, (a) In some cases these 
fibres proceed from prolongations of the nerve-cells. (6) But, most commonly, 
they arise in groups, without its being possible to determine their origin. 
These fibrous groups traverse the white substance in different directions, in 
order to form the roots of the nerves at the surface. They never contribute to 
the development of the white substance, nor does the latter furnish any fibres 
fur the roots of the spinal nerves. 9. That the motor roots of the spinal nerves, 
and of the motor cerebral nerves, such as the hypoglossal, the external and in- 
ternal motors of the eye, the facial, the small portion of the trigeminus, and the 
common ocular motor, take their origin only in the motor columns. 10. That 
the sensitive roots of the spinal nerves, and of the sensitive cerebral nerves — 



240 



Progress of the Medical Sciences. 



[Jan. 



as the auditory, the large portion of the trigeminus, the optic, and olfactory — 
proceed only from the sensitive columns. 11. That the roots of the mixed cere- 
bral nerves, as the two superior roots of the accessory nerves of Willis, and the' 
pneumogastric, arise in both the motor and sensitive columns. 12. That there 
are four kinds of crossings in the spinal marrow, medulla oblongata, and pons 
Varolii, (a) In the spinal marrow, the primary fibres of the motor roots cros3 
in front of the central canal, and the fibres of the sensitive roots cross behind 
it. These intra-crossings are produced by a portion of the primary fibres of 
the roots taking their origin in the opposite side, (b) In the medulla oblongata 
and pons Varolii, the primary fibres of the roots of the cerebral motor nerves, 
and only the motor portion of the mixed cerebral nerves, intercross at the mid- 
dle of the motor columns, for the same reason as in the spinal marrow, (c) 
In the cloison of Vicq d'Azyr there is an intercrossing from right to left of 
some of the fibres of the white substance of the medulla oblongata, and of the 
pons Varolii, (d) There is a crossing of the six walls of the fasciculi of the 
white substance, and of the medidla oblongata, in front of the central -canal, 
known under the name of the pyramidal decussation. 13. That the primary 
fibres of the roots of the nervous plexuses of the pia mater, as also those of all 
the roots of the accessory nerves of Willis (except the two superior roots), arise 
from all the periphery of the gray substance. In the plexuses at the surface 
of the pia mater are found : (a) Nerve-cells interposed between the primary 
nervous fibres. (6) Nerve-cells in groups, suspended and floating at the ex- 
ternal surface of the nerves of the pia mater. These latter are filled with 
pigment. 14. That the two olivary bodies are composed of two substances, an 
external, gray, having convolutions, and an internal, white. The white sub- 
stance is formed by the irradiation of the primary fibres of the peduncles of 
these bodies, which take their origin in the motor columns, and by the trans- 
verse commissure which traverses the cloison of Vicq d'Azyr. 15. That the 
central canal of the spinal marrow runs along its entire length, and opens into 
the calamus scriptorius. The walls are formed internally by a covering of 
cylindrical epithelial cells, and externally by a layer of the longitudinal fibres 
of Clarke, which extend into the epithelial layer of the rhomboidal sinus. In 
the lumbar region a granular mass is interposed between this fibrillary layer 
and the epithelial cells. 16. That on each side of the central canal there is a 
large vein, which successively bifurcates in the region of the medidla oblongata, 
and in that of the medullary cone." — Moniteur des Hopitaux, Oct. 27, 1857. 

3. On the Nerves of the Intestinal Walls. — G. Meissner looks upon the areolar 
tissue between the muscular and the mucous coats of the intestines as one of 
the parts most richly supplied by nerves in the entire body. These nerves, by 
numerous anastomoses, form a network, the finest twigs of which appear to 
penetrate the muscle. The primitive fibres for the most part, and perhaps 
entirely, belong to the kind without any double contour, and are beset by 
numerous nuclei. They form the finer and thicker branchlets, and are com- 
prised in nucleus-holding sheaths, in numbers varying from five to twenty ; 
whilst the finest branchlets only contain from two to three primitive fibres. 
The small intestines appear to be the most rich in nerves, but in the walls of 
the stomach the nerves are very sparing. In the walls of the intestine the 
number of ganglia in the nervous plexuses is immense, corresponding for the 
most part with the thickness of the nerve-branches in which they are found ; 
and in the small intestines almost every nerve-branch leads to a ganglion. The 
largest observed by the author consisted of from thirty to fifty cells ; but they 
ordinarily contained from five to ten, having the ordinary appearance of gan- 
glion cells. In man, pigment granules were often to be seen as contents of the 
cells, but in the calf they were found to be quite clear and colourless. Many 
of the cells were bi-polar, and this was evident whenever a single cell was seen 
inserted in the course of a primitive fibre without a ganglion being formed. 
Such cells were generally spindle-shaped, and projected themselves at opposite 
poles into a fibre. Besides bi-polar cells, some were seen from which, either 
at one side or both poles, two fibres passed close to each other. The ganglia 
in the stomach are not relatively less than in the intestine. The ganglion cells 



1858.] 



Anatomy and Physiology. 



241 



in the stomach are larger than those of the intestinal walls. The author de- 
scribes the best method of examining the nerves and ganglia of those parts, 
and speaks of the fresh intestine being sufficient, by the aid of acetic acid, for 
the examination ; but inasmuch as this method is tedious, moderately concen- 
trated pyroligneous acid affords the greatest help, which, after some time, 
makes the areolar tissue very transparent, leaving the nerves and ganglia un- 
altered. After dilute pyroligneous acid has acted for some days, acetic acid 
proves very serviceable. — Brit, and For. Med.-Chir. Review, Oct., 1857, from 
Henle und Pfeuffer's Zeitschrift, Bd. viii. Heft 2. 

4. On the Function of tlie Thyroid Body. — Dr. Peter Martyn communicated 
to the Royal Society a paper on this subject. After referring to the form, 
situation, connections, and internal structure of the thyroid body, its 'large 
supply of blood, and its capability of sudden alterations of bulk, the author 
briefly adverts to the unsatisfactory explanations which have been offered as to 
its function, and then proceeds to state his own views, as follows : — 

" The upper part of the trachea, the larynx, and the passage of the fauces 
and mouth constitute the organ of voice ; the two former are the essential or 
voicing part, as mechanicians call it, that which produces the tone. The 
larynx and trachea — taking a share in other functions and being associated by 
juxtaposition and attachment with contiguous organs — are always pervious 
and open for respiration ; lengthen and shorten, fall and rise with the oeso- 
phagus in deglutition, and bend and turn with the universal motions of the 
head and neck. 

" To admit of this great mobility and flexibility, a certain structure is neces- 
sary. The larynx is a triangular box, inclosing the apparatus of the chords 
vocales ; its two cartilaginous sides or alas, diverging from the front, are not 
fixed, but free at the back, being completed by soft parts ; the trachea is com- 
posed of a succession of incomplete cartilaginous hoops or rings lying apart, 
the back and intervals being made up and the tube completed by soft mem- 
brane. 

" Now the structure of a wind instrument, such as that of the human voice, 
requires the opposite properties. It must be rigid, tense, and inflexible. The 
qualities of the tone will be in exact proportion to these properties. How, 
then, is the soft, slack, and flexible vocal tube rendered thus rigid, tense, and 
inflexible, and fit to produce pure tone ? The muscles of the larynx, the thyro- 
hyoid and sterno-thyroid, merely raise or lower, or fix it in any position: not 
lying on, or being parallel to, but diverging from the vocal tube, they cannot 
affect the object referred to. It appears to me that the thyroid body is pro- 
vided for this purpose. The act of uttering a tone or of speaking stops the 
return of the blood from that organ, distends and renders it tense, and from 
the nature of its attachment round the top of the trachea and on the free sides 
of the alae of the larynx, renders them fixed, firm, and tense also. This effect 
is aided by the aforesaid muscles, the thyroid body being interposed and giving 
them more advantageous mechanical action. The tension may be in any de- 
gree, and on energetic speaking or singing, the increased size of the part and 
the fulness of the collateral veins may be seen. This is the reason of its large 
supply and free distribution of blood. An instance of the want of this tension 
in an instrument may be seen in the bagpipe, where the porte-vent is attached 
to the chanter or voicing part by a flexible joint or by leather, and the tone is 
in consequence squeaking and uncertain. 

" Besides' thus giving rigidity, firmness, and tension to the organ of voice, 
the thyroid body also acts in another capacity — as a loader. In most musical 
instruments, loaders are used to render the vibrations slower and longer, and 
the tone in consequence fuller, louder, and deeper. They compensate for want 
of size and space, and give to a small instrument, or to a small vibrating or 
voicing part of an instrument, the power and quality of a large one. The hu- 
man organ of voice is 8 inches long, and has the same power as, and better 
quality of tone than, the instrument that most nearly approaches it — the 
French horn, which is 9 feet, or the 'vox humana' pipe of a moderate-sized 
organ, which is from 4 to 8 feet long. This economy of size in the human 



242 



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[Jan. 



organ has always been wondered at, but never, that I know, explained. Be- 
sides the thyroid body, another part, the structure of which I shall describe 
on another occasion, aids in this admirable economy. The nearer mechanism 
of human design approaches to perfection, the more it resembles similar struc- 
tures in animal mechanics. The base of all stringed instruments and musical 
boxes is loaded: in most wind instruments the voicing part is thus loaded and 
strengthened, as in the organ-pipe, horn, flute, clarionet, &c. The bassoon, 
which in its lower notes approaches the human voice, is uncertain and wheezy 
in tone for want of this provision. 

" When the thyroid body is small and thin, the voice will be found to be 
small and shrill ; when large, the tone will be full and sonorous; when it is 
morbidly enlarged, the voice will be deeper and more base; and when very 
large, as in bronchocele, the voice will be smothered. 

" The compass of the voice is in great part produced by the raising and 
lowering of the larynx, the shortening and lengthening of the vocal tube. The 
thyroid body partakes of this motion, at the same time firmly fixing and ren- 
dering tense the parts in each position. By its change of shape, bulk, and 
density — flattening and thinning when the larynx is raised, enlarging and 
bulging when it is lowered — it aids in giving the particular tone or pitch, high 
and acute in the first case, full and deep in the second ; and, in like manner, 
by its varying shape, bulk, density, and pressure, it takes a great part in pro- 
ducing the wonderful qualities of modulation and expression peculiar to the 
human voice. In animated conversation, declamation, and singing, this may 
be seen. 

" Its function then appears to be threefold — rendering the slack, mobile, and 
flexible vocal organ or tube rigid, tense, and inflexible, and fit to produce pure 
tone ; by its bulk and density acting as a loader and strengthener, making the 
tone more sonorous, full, and deep, and thus compensating for want of length 
and size in the organ ; and finally, by its varying shape, bulk, density, and 
pressure, furnishing an important aid in producing the inimitable qualities of 
modulation and expression enjoyed by the human voice. 

" That it is a part of the organ of voice and an important accessory in giv- 
ing it perfection, may be inferred also from its situation on the larynx and 
trachea, and its being supplied by the same nerves — its being largest in man, 
where the voice and speech are perfect — its being proportionally larger in wo- 
men and children than in men, their smaller and more mobile organs requir- 
ing its peculiar aid. Among the lower animals, it is present (at least in a 
fully developed condition) only in the Mammalia, but among them there is a 
remarkable exception in the Cetacea — they have it not, and they have no voice. 
In Birds, which have such great power and modulation of voice, the structure 
of the vocal organ and tube is different from that in man, and sufficient in 
itself to produce these qualities. 

" The importance of the thyroid body must be admitted when it is shown to 
be necessary for the perfection of the voice, and hence of speech—that great 
and indispensable agent in the cultivating and advancing the highest faculties 
of man." — Med. Times and Gaz., Oct. 24, 1857. 



ORGANIC CHEMISTRY. 

5. MeiJiod of Clinically Determining the Amount of Sugar in Diabetic Urine. — 
Dr. Garrod brought before the Medical Society of London (Oct. 10, 1857) a 
method recently discovered by him of clinically determining the amount of 
sugar in diabetic urine, exhibiting at the same time a small instrument, named 
a Glucometer. 1 It is constructed upon the fact that glucose, or diabetic sugar, 
when boiled with a solution of carbonate of potash, gives rise to an amber 

1 The instrument is manufactured by J. Coxeter, Grafton Street East. 



1858.] 



Organic Cliemi&try. 



243 



colour, and that the tint is in proportion to the quantity of sugar. The appara- 
tus consists of a standard, a graduated tube of the same calibre as the standard, 
and an accurately divided minim measure, the standard being filled with a 
solution of the exact tint produced by a known quantity (half a grain) of the 
diabetic sugar to the fluid ounce. The following is the method of using the 
glucometer : A small quantity of the urine, say half a fluidrachm, either 
previously diluted or not, according to circumstances readily ascertained, is to 
be accurately measured in the small minim tube, and mixed with the same bulk 
of a solution of carbonate of potash of a given strength, and after the measure 
has been washed out with a drachm or two of distilled water, the whole is to 
be kept at the boiling point over a spirit-lamp for five minutes, either in a large 
test-tube, or, still better, a very small flask. After cooling, the coloured liquor 
should be transferred to the large tube, and distilled water added until the tint 
exactly corresponds to that of the standard — a process which may be readily 
effected by holding the tubes side by side, directing them to a moderately bright 
light. All the required data for determining the amount of sugar are now ob- 
tained. Suppose, for example, that the half drachm of urine employed in the 
quantitative analysis requires to be diluted so as to occupy six and a half 
drachms before the standard tint is obtained, such urine would contain six 
grains and a half of sugar per ounce; for its bulk has been increased thirteen 
times, and therefore thirteen half grains, or six grains and a half, of sugar 
must be present. Again, suppose the urine had been diluted with three times 
its bulk of water before being employed in the glucometer, which when the 
urine is rich in sugar may be necessary, in order to prevent the graduated tube 
being of inconvenient length, then it is only required to multiply the amount 
of sugar by four to obtain the total quantity in the original urine. In the 
above-named experiment it would therefore be twenty-six grains in each fluid- 
ounce. Dr. Garrod alluded to various methods which had from time to time 
been employed for the purpose of ascertaining the amount of sugar in the urine 
in cases of diabetics; showed the difficulties which most or all of them pre- 
sented, especially to the medical practitioner, which was practically proved by 
their non-employment, and expressed a hope that by means of the glucometer 
the clinical determination of sugar might become a matter of little difficulty, 
and capable of being effected by any one engaged in the practice of medicine ; 
and he also considered that such determination might prove of great value, not 
only in ascertaining the amount of disease under which any diabetic subject 
might be suffering, but also the value of various articles of diet and of different 
remedies in the treatment of this most important disease. — Lancet, Oct. 17, 1857. 

6. Mode of Detecting Sugar in the Urine, and on the Different Nature of certain 
Forms of Diabetes. — Dr. A. Becquerel, Physician to the Hospital of La Pitie and 
Professor Agre'ge' to the Faculty of Medicine of Paris, has recently submitted 
a notice on this subject to the Medical Society of the hospitals there. 

In this communication he says: "Five years ago, in my Treatise on Patholo- 
gical Anatomy, and four years ago, at the hospital of Lariboisiere, in a series 
of lectures reported in the Moniteur des Hopitaux, I pointed out the following 
facts : First. That nearly all urines become discoloured, impart a green colour 
to, and even precipitate the cupro-potass solution of Barreswil, or that of From- 
merz, if heated with these reagents. Second. That a great number of these 
same urines become brown, in like manner, on the addition of caustic potass, 
however pure that may be. 

"Nearly u year ago, in a new series of lectures delivered at the hospital of 
La Pitie, I again strongly insisted on the erroneous conclusions to which the 
reaction afforded by these tests might lead; an opinion which was merely that 
prevailing among chemists who had paid attention to this subject at the time. 
I shall content myself here by showing you that nothing is more easy than to 
avoid this source of error, and that there is at our disposal a much more sure, 
expeditious, and certain method of detecting the presence of sugar in the urine 
than is usually employed. 

"We take a certain determinate quantity of urine, say 60 grs.; this we treat 
with a small quantity of solid and crystallized acetate of lead, say 4 grs. ; on 



244 



Progress of the Medical Sciences. 



[Jan. 



heating this mixture, there is immediately formed a copious precipitate of a 
dirty white colour; the liquor is then to be filtered, and the solution treated by 
sulphate of soda in excess. If, for example, we have added 4 grs. of acetate 
of lead, we add 8 grs. of sulphate of soda. This being done, the mixture is 
again heated, and sulphate of lead is deposited ; we then filter once more, and 
there is afforded a clear transparent liquid, which contains the sugar, when 
there is any, and some unimportant salts. The liquid thus obtained is neither 
acted on by the cupro-potass reagents, nor browned by the caustic potass, unless 
sugar is present. These two reagents are in this way perfectly reliable, very 
accurate, and afford no results when no sugar is contained. 

" Should the urine under examination contain albumen, it is immediately 
coagulated by the acetate of lead at the same time as other organic matters, 
and gives no further trouble. 

" Thus, in all cases where it is desired to ascertain the existence of sugar in 
the urine, whether along with albumen or not, we possess two excellent re- 
agents in the cupro-potass solution, and in the caustic potass itself ; only we 
require, in the first place, to treat the urine with the acetate of lead and the 
sulphate of soda, by which means we get rid of all such matters as decompose 
or discolour the cupro-potass or caustic potass tests. 

" Since January, 1855, up to the present time, the urine of all the patients 
under my care — and these have amounted to nearly 2000 — has been examined 
according to the above method. But besides this, in all cases where the pre- 
sence of sugar was determined, there was also an examination made by means 
of the polarimeter, in order to discover the precise quantity of that principle 
contained in every thousand grains of urine. These numerous cases have 
afforded some curious results which I would desire to lay before the Society. 

"Two species of diabetes appear to exist, viz., idiopathic diabetes, or diabetes 
properly so called, and symptomatic diabetes. With reference to diabetes pro- 
perly so called, I have here nothing to say ; it is a disease special in its causes, 
and having an origin, a progress, and a termination altogether peculiar to itself. 
That to which I at present allude is a disease of a somewhat different nature, 
viz., symptomatic diabetes. By this name I would refer to a certain number 
of cases in which the presence of sugar in the urine constitutes an accessory 
or supervening symptom. This is a symptom which, like albuminuria, is com- 
mon to very different diseases, and one which would never be suspected unless 
the urine were submitted to examination. 

"The characters of symptomatic diabetes are as follows: — 

"1st. The quantity of sugar contained in the urine is never very great, al- 
though I have frequently found as much as 25 or 26 grs. in 1000, which is a 
pretty considerable proportion, but less than exists in idiopathic diabetes, where 
it often reaches as high as 40, 50, 60, and even 80 grs. in 100. 

"2d. The urine is very little or never increased in quantity. 

" 3d. Although the density of the urine is no doubt increased, yet it is only 
to a very slight extent. 

" 4th. The sugar does not alter the other chemical elements contained in the 
urine. 

"5th. There are no phenomena present attributable to the fact of sugar being 
contained in the urine; there is neither the increase of appetite, nor the immo- 
derate thirst of idiopathic diabetes. 

" Symptomatic diabetes shows itself occasionally in diseases of the brain and 
spinal cord, of the liver, of the digestive apparatus ; in disease connected with 
parturition and lactation ; and in other affections of various descriptions." — 
Ed. Med. Joum., Nov. 1857, from U Union Medicate, Aug. 1857. 

7. On the Presence of Sugar in the Urine of Pregnant, Parturient, and Puer- 
peral Women. By Theodore Kirster, of Leipzig. — The researches of Blot on 
the presence of sugar in the urine of pregnant, parturient, and puerperal wo- 
men, suggested to Dr. Kirsten the expediency of independent inquiries with a 
view to the verification of Blot's results. M. Blot arrived at the conclusion 1 



1 See Midwifery Report, British and Foreign Medico-CMrurgical Review, April, 
1857. 



1858.] 



Organic Chemistry. 



245 



that the presence of sugar in the urine of women under these circumstances 
was a physiological phenomenon ; and that its disappearance was the result of 
an intercurrent pathological condition. Dr. Kirsten observes, that if this con- 
clusion were true we should possess in the disappearance of the sugar a tolera- 
bly sure measure of the condition of a puerperal woman, since this would 
indicate a commencing pathological disturbance, whilst its return would indi- 
cate reconvalescence. Dr. Kirsten examined the sugar relations in two women. 
His observations do not altogether accord with those of M. Blot : they rather 
point to the reverse condition — namely, that sugar is present in greatest quan- 
tity in the urine of puerperal women when the milk-secretion — whether through 
a pathological process, or the weaning of the child — is arrested. Thus he 
observed in several puerperal women whose children had died, that on the 
second, third, or fourth day after the death the sugar appeared in greatest 
plenty. After this time, the quantity fell in the same degree as the milk 
diminished ; but in four cases it could be demonstrated twelve days later. In 
three cases in which the patients were seriously ill in the puerperal state, and 
in whom the milk-secretion was almost null, the sugar was found in greatest 
quantity. One of these last women had suffered from common oedema during 
pregnancy. The examination of her urine revealed copious albumen, which 
diminished with the oedema, without disappearing altogether. Towards the 
end of pregnancy traces of sugar became apparent. She was delivered easily 
of a badly-nourished child. Repeated attacks of peritonitis followed. The 
milk-secretion was very scanty, and the milk very thin : sugar was present in 
the urine in abundance. In the second patient, who suffered from peritonitis, 
followed by pyaemia, Dr. Kirsten was able to detect sugar up to the day before 
her death, this substance having been present in great quantity at the begin- 
ning of her illness. The third case was quite similar. On the other hand, he 
was rarely able to discover more than mere traces of sugar in the most healthy 
women, who had well-nourished children and a superabundance of milk. 

It hence appears that glycosuria belongs rather to pathology than to physio- 
logy. The key, Dr. Kirsten thinks, is to be found in the most recent researches 
of Bernard. This physiologist has shown that the formation of sugar in the 
liver is especially apparent when the abdominal circulation is increased, and 
the temperature rises. The biliary matter chiefly turns into sugar at a tem- 
perature of 40° Cent. No time was more favourable for this transformation 
than gestation, when the abdominal circulation and temperature are always 
raised to the necessary point for sugar-formation : whence we ought always to 
expect glycosuria in pregnant women. But as this is not the case, we are 
obliged to conclude that the greater quantity of sugar produced at this period 
is wanted for the nourishment of the child, so that it cannot be excreted. It 
would be interesting, with a view to the verification of this hypothesis, to ex- 
amine the urine of women whose children may die, as quickly as possible after 
their death. 

During the puerperal week the abdominal circulation is lessened, and the 
afflux of blood takes place towards the periphery, as is evidenced by the milk- 
secretion and sweats. This condition would not be favourable to the formation 
of sugar. — Brit, and For. Med.-Chirurg. Review, October, 1857, from Monatsschr. 
f. Geburtsk, June, 1857. 

8. On the Elimination of Sulphuretted Hydrogen by the Lungs. — M. Cl. Ber- 
nard desires to contribute to the solution of the question, why it is that sul- 
phuretted hydrogen, which can be swallowed in large quantities with impunity, 
will cause the death of a medium-sized dog, when breathing in the proportion 
of g Jo, and of a horse, when in the proportion of Two hypotheses may 

be raised. Either it is not absorbed in the alimentary canal, but digested, and 
its peculiar effects neutralized; or, after becoming absorbed, it is modified, and 
eliminated before it can reach the arterial system : the arterial blood being, in 
fact, the immediate vehicle of all physiological and toxical action, inasmuch as 
it is it which passes directly to the capillaries, where all organic changes take 
place. In the event of this last hypothesis being the correct one, we have to 
determine by what organ the elimination is accomplished. The pulmonary 



246 



Progress of the Medical Sciences. 



[Jan. 



surface would seem best adapted for the exhalation of this gaseous poison ; so 
that it would sometimes perform the part of an absorbent surface, as when the 
sulphuretted hydrogen was contained in the air, or of an exhalant, when this 
substance existed in the blood. This example, which is by no means an isolated 
one in the economy, would seem to prove that the mucous surfaces, often indif- 
ferent in themselves^ have no special action in relation to a substance, beyond 
that which is determined by the conditions under which such substance is pre- 
sented to them. 

M. Bernard performed numerous experiments in order to show that the elimi- 
nation really takes place by the lungs. It was found that after throwing in 
the gaseous sulphuretted hydrogen, or a saturated solution of it, into the jugu- 
lar, paper soaked in acetate of lead held at the nostrils became speedily black- 
ened, and that almost immediately the substance entered the blood. This was 
repeated at intervals several times, without the animal seeming to suffer incon- 
venience. No ill effects result, because the substance is eliminated before it 
can reach the arterial system; while, when it is inspired with the air, the ab- 
sorbed sulphuret is carried by the pulmonary veins directly into that system. 
In order to show that pulmonary elimination also takes place when the gas is 
introduced into the digestive canal, sulphuretted hydrogen was also injected 
into the stomach and into the rectum. When thrown into the stomach, the 
paper was found blackened after some seconds; but with respect to the rectum, 
this effect was not observed until sixty-five seconds after, the elimination not 
being completed under five minutes. 

Owing to the facility of its elimination, M. Bernard suggests that sulphuretted 
hydrogen might possibly serve as a measure of the rapidity of certain physio- 
logical actions, and especially of the phenomena of absorption and circulation. 
Two experiments are related in illustration: three cubic centimetres of satu- 
rated solution of sulphuretted hydrogen were thrown into the jugular vein, and 
the first spot appeared on the paper at the end of three seconds. The same 
quantity was thrown into the femoral vein of the same dog, and the earliest 
manifestation took place only after six or seven seconds. When the quantity 
injected did not exceed that mentioned above, two or three expirations, and 
sometimes a single one, sufficed for the complete elimination of the sulphuretted 
hydrogen. 

The question arises whether, when we introduce sulphuretted hydrogen 
either into the natural channels of absorption, or into the veins, the whole of 
it becomes eliminated by the lungs. Doubtless, by accurate measurement, this 
could be determined, but the probability is that it is not the case. Independ- 
ently of other channels of elimination that may exist, it is probable that some 
of the sulphuretted hydrogen remains in the blood in the state of sulphur. 
Thus, when small quantities of the sulphuretted hydrogen are injected at a 
point as distant as possible from the lungs, no pulmonary elimination takes 
place, probably because there has been time for the whole to become modified 
and changed into sulphur before reaching the lungs. It was found that inject- 
ing small quantities into the carotid was followed by no elimination, until the 
repetition of the operation gave rise to a certain amount of saturation. Another 
proof that some of the sulphuretted hydrogen is retained in the blood, probably 
as sulphur, is found in the fact that in blood drawn from the animal, and mani- 
festing no odour of sulphuretted hydrogen, the addition of hydrochloric acid, 
and the application of heat, lead to the disengagement of this gas. 

The experiments made require to be repeated and multiplied, in order that 
the action of sulphuretted hydrogen on the economy should be completely 
studied. An important fact has, however, been thus far determined, viz., its 
great tendency, when circulating in the blood, to become eliminated by the 
lungs: and it may be asked whether such elimination is any way related to the 
therapeutical effects attributed to sulphureous medicines in certain affections 
of the chest. — Med. Times and Gaz., Sept. 5, 1857, from Archives Gtn., torn. ix. 

9. Starch from the Animal Kingdom. — Dr. Pavy exhibited to the Medical 
Society of London (Oct. 10, 1857) some of the newly discovered amylaceous 
material which is obtainable from the healthy liver, and which forms the source 



1858.] 



Organic Chemistry. 



247 



of the animal sugar. In referring to the history of the saccharine secretive 
function of the liver, Dr. Pavy stated that, upon the announcement of the dis- 
covery by Bernard in 1848 that sugar was formed in the animal body, it was 
referred to a transformative action of the liver on an albuminous constituent 
of the portal blood. The celebrated experiment of puncturing the floor of the 
fourth ventricle, and establishing diabetes, rather supported this view; for it 
was thought that the irritation of the nervous centre stimulated the secretory 
action of the liver, and led to the production of a superabundance of sugar, 
which, accumulating in the circulatory system, was pumped off by the kidneys, 
and thus appeared in the urine. The next step of information removed the 
direct influence of the nervous system, and showed that the production of sugar 
could not be regarded as analogous to the process of secretion. In September, 
1855, in fact Bernard announced, at the Academie des Sciences, that the forma- 
tion of sugar continued for as many as twenty-four hours after death in a liver 
from which the blood had been entirely removed. If, for instance, the liver of 
a healthy animal be removed immediately after death, and a current of water 
be injected from the portal vein through its vessels, the whole of the blood is 
washed out, and the organ is also quickly deprived of the saccharine material 
it contained. Now, if such a liver be placed on one side and examined in a 
few hours' time, it will be found to have become strongly impregnated with 
sugar, the production of this material having continued in the exsanguine tissue 
of the gland-. Upon this fact our knowledge had rested until within the last 
few months. During the early part of the summer, Dr. Pavy had noticed, whilst 
conducting his experiments on the destruction of sugar (which have led him to 
new and unexpected results, which he will shortly communicate to the profes- 
sion), that he could isolate a material from the liver which subsequently under- 
went transformation into sugar ; and he had recorded in his laboratory book the 
influence of chemical agents, such as acids, alkalies, and alcohol, on this ma- 
terial. He had since learnt, however, on his recent visit to Paris, that Bernard 
had most satisfactorily made out the nature and relations of this body, which, 
from the analogy presented in its chemical bearings to starch, he had called an 
animal amylaceous or starchy material. It had also been called glucogenic 
material, and this was probably the best term to apply to it at present, because 
it implied nothing more than we knew the substance in reality to be. The 
specimen of this glucogenic material which Dr. Pavy exhibited had been pro- 
cured from the liver of a dog in the following manner: The dog had for some 
days been submitted to a strictly animal diet, so as to preclude the introduction 
of any starchy material into its system from the vegetable kingdom. After 
killing the animal, by the destruction of the medulla oblongata, the liver was 
removed, and a tube firmly ligatured in the portal vein, for the purpose of pass- 
ing a current of water through the vessels to wash out the blood, and at the 
same time remove the sugar. In half an hour's time the water which had 
passed through the vessels was colourless and destitute of sugar, as was also the 
tissue of the liver itself. The organ was now cut up into small slices, placed 
in an evaporating dish, boiled in the liquid which exuded from it, and subse- 
quently strained and pressed to obtain all the liquid that was procurable. The 
object, in fact, was to make a decoction of the liver, which holds in solution 
the glucogenic material, and has, thereby, communicated to it an opalescent 
or a milky appearance. This was then mixed with alcohol (in the proportion 
of one part of the decoction to about five of the spirit), and immediately a pre- 
cipitate was produced, which was collected on a filter and dried, and formed 
the specimen then before the fellows of the Society. The substance before him 
was of a grayish colour, which resulted from contamination with albuminous 
matter. It might be made perfectly white by prolonged boiling in a solution 
of potash, which did not at all affect its properties. It was insoluble in alcohol 
and strong acetic acid. Its solution in water presented the same milky appear- 
ance as the fresh decoction of liver. It gave no reaction with the sugar tests, 
nor was it susceptible of undergoing fermentation. It was, however, readily 
convertible into dextrine and sugar by the same agents which produced this 
change in the starch of the vegetable kingdom. Indeed, boiling with acids and 
contact with diastase, saliva, pancreatic juice, blood, or any animal matter in 



'I 



248 Progress of the Medical Sciences. [Jan. 

a state of change, very readily effected its transformation into glucose, when it 
gave all the characteristic reactions of this substance. Dr. Pavy further stated, 
that by means of chemical agents and the microscope the natural seat of this 
material could be shown to be in the interior of the hepatic cells. — Lancet, Oct. 
17, 1857. 

10. On the Immediate Principles of Human Excrements in the Healthy Stale. — 
Dr. W. Marcet communicated the following paper to the Royal Society : — 

In a previous paper, I had the honour of communicating to the Royal So- 
ciety the results of a first series of investigations on the immediate principles 
of the feces of man and animals ; since then I have continued my researches 
on human excrements, being most ably seconded by my assistant, Mr. Fred- 
erick Dupre, Ph.D. 

The new results obtained were the following: — 

1. Margarate of lime, phosphate of lime, and margarate of magnesia were dis- 
covered to be immediate principles of human evacuations. 

2. I found a new method for obtaining excretine, and its chemical formula 
has been established. 

3. The fact that vegetable food induces the presence of margaric acid in ex- 
crements has been confirmed. 

4. The existence of a comparatively large quantity of cholesterine in the 
spleen, which I had mentioned before as probable, has been confirmed. 

When human feces are exhausted with boiling alcohol, the fluid being 
rapidly strained through a cloth, a clear extract is obtained, which, in cooling, 
yields a deposit; this substance being collected on a filter, is partly soluble in 
boiling alcohol, and there remains undissolved a residue insoluble in ether and 
alcohol. The residue in question being boiled with a solution of potash, dis- 
solves almost entirely, and the addition of hydrochloric acid induces the forma- 
tion of a precipitate in the solution. On examining this precipitate, it was 
found to consist of a crystallizable substance fusing at 60° Cent. : its structure 
and other properties were precisely those of margaric acid. 

The acid filtrate contained phosphoric acid and lime. From several quanti- 
tative analyses, I concluded that there was more lime than is required to com- 
bine with the phosphoric acid in the form of the neutral phosphate, the excess 
of lime being exactly that which was necessary to convert the margaric acid 
into a neutral margarate of lime, C 34 H S3 +0 3 CaO. Consequently it followed 
that the three substances existed in the form of margarate of lime and phosphate 
of lime as immediate principles of human feces. 

The alcoholic filtrate from the deposit being allowed to stand for twenty-four 
hours, deposited another substance, of a nearly white appearance, and which 
proved to be margarate of magnesia. 

The peculiar action of a vegetable diet on human feces was investigated by 
means of experiments undertaken upon myself, when I observed that an en- 
tirely vegetable diet was attended with the formation of a large quantity of 
margaric acid in the excrements — most probably not in the form of a marga- 
rate, but in the free state, inasmuch as it was obtained from the decomposition, 
with hydrochloric acid, of the precipitate induced by adding milk of lime to 
the cold and clear alcoholic extract of feces, after the separation of the above- 
described deposits. 

In the month of December, 1855, I had an opportunity of noticing that dur- 
ing a cold night, when the temperature falls below the freezing point, excretine 
crystallizes readily and in large quantity in the clear alcoholic extract of 
feces ; this method I employed as often as possible, to prepare enough excre- 
tine for its chemical analysis; but the cold weather not lasting long enough, 
and this season having been remarkably mild, I was compelled to adopt a 
modification of the process by milk of lime, described in my former com- 
munication. 

Having prepared a sufficient quantity of excretine partly by the action of 
cold, and partly by means of milk of lime, the chemical composition of this 
substance was now determined. A qualitative analysis showed it to consist of 
carbon, hydrogen, sulphur, and oxygen (a) ; there was no water of crystalliza- 



i 



1858.] Materia Medica and Pharmacy. 249 

tion present. Oxide of copper was employed at first for the combustions, but 
they were subsequently undertaken with chromate of lead, on account of the 
large proportion of carbon that excretine contains; no substance having been 
found to combine with it, its atomic composition was calculated from the 
assumption that one equivalent contained one equivalent of sulphur; and the 
following formula was obtained : — 

78 eq. Carbon . . ... .468 

78 eq. Hydrogen 78 

• 1 eq. Sulphur 16 

2 eq. Oxygen 16 

Atomic weight of Excretine 578 

In my former communication I had stated that when the tissue of the spleen 
is submitted to a process of analysis similar to that adopted for the extraction 
of excretine, a substance closely allied to cholesterine is obtained. This sub- 
ject being one of great importance in a physiological point of view, I have 
resumed the investigation, and placed beyond doubt that this substance is 
really cholesterine. Its presence in the spleen is evidently independent of that 
which might exist in the blood retained by this organ after death. Is it that 
the spleen secretes cholesterine ? This can only be determined by actual ex- 
periment ; but it is very remarkable that a part of the blood which is supplied 
to the liver should come directly from an organ containing large quantities of 
a substance known to enter into the composition of the bile. — Med. Times and 
Gaz., Oct. 24, 1857. 



MATERIA MEDICA AND PHARMACY. 

11. Permanganate of Potash as a Caustic, Deodorant, and Stimulant. — Dr. D. 
F. Girwood extols [Lancet, Sept. 12, 1857) the permanganate of potash as a 
caustic, deodorant, and stimulant, and if what he states in regard to it shall be 
confirmed by the experience of others, it will be a most valuable medicinal agent. 

"As a deodorant, as an escharotic, as a stimulant," he asserts, "it is a most 
useful application, combining, as it does, all these three qualities." 

In a case of cancer of the os uteri, Dr. G. employed it in the double capacity 
of deodorant and escharotic, to destroy the fetid odour and to check the ex- 
uberant granulations, and induce a healthy appearance of the ulcerated 
surface. He injected twenty grains to the pint of water frequently during the 
day, with much benefit. 

In a case of cancer of the breast he applied it in powder sprinkled on the 
sloughy mass, and as a lotion (ten grains to the ounce). From a gaping sore, 
in most offensive condition, it occasioned the wound to assume in some parts a 
disposition to granulate, and it entirely removed the offensive odour of the 
apartment. 

In various other cases of offensive ulcers he has used it with equal advantage. 

When it is wished to destroy masses of cancerous growth Dr. G. uses it in a 
solid form, either as a powder, or in a mass as the sulphate of copper or other 
caustics. A piece of lint wet with the lotion, of the strength of two to twenty 
grains, Dr. G; says, supersedes all the charcoal, yeast and carrot poultices. 

A teaspoonful of the substance mixed with a tablespoonful of water in a 
dinner plate, and placed under the bed or anywhere convenient destroys all 
odour, and it has this great advantage over other deodorants, that it has no 
odour of its own. Most deodorants are themselves a nuisance, for while 
destroying one odour they create another; the permanganate is free from this. 

12. On the Oriental Bath. — Dr. Haughton read before the Physiological 
Section of the British Association at its recent meeting at Dublin, the following 
interesting paper on this subject: — 



250 



Progress of the Medical Sciences. 



[Jan. 



" Some months ago, my attention being drawn to the oriental bath as a 
sanitary institution, I was induced to undertake a journey to the East, for the 
express purpose of determining what were its claims to consideration ; and 
with this view I remained a month in Constantinople, collecting whatever in- 
formation was to be had upon this subject, which is now commencing to attract 
so much attention in this country. 

" This bath is best known to the western nations by the name of ' The Turkish 
Bath/ having been described under that title in most of the accounts which 
have appeared before the British public ; but the truth is, that there is scarcely 
a nation in the East which does not possess a somewhat similar institution. 
There is a prevailing prejudice that the Eastern bath is only suited for tropical 
climates, and could not be adopted in these latitudes without danger ; but we 
find that not only the ancient Greeks, but also the Romans, were acquainted 
with its virtues, and thought no expense too great to enable them to confer 
upon every citizen the luxury of cleanliness, the foundation of all sanitation. 

" It was the custom of the Romans to build baths in the different countries 
which they conquered; and accordingly the historian Justin informs us that 
they introduced them into Spain, after the second Punic war, where they con- 
tinued in operation long after their suppression in other parts of Europe. 
From thence, according to Baccius, they passed into Germany and France, and 
even into the British Islands ; and there is reason to believe, that were anti- 
quarian research directed to this point, remains would be found in these 
countries, not upon the same scale as those of France and Germany, but suffi- 
ciently perfect to show the principle upon which they were constructed. It is 
of great importance that this principle should be well understood, and espe- 
cially that we should observe the difference between it and the Russian vapour 
bath, which it most resembles. It is simply that of an oven, large enough to 
walk about in, and lighted from the top, that you may see what you are doing. 
The medium by which the bather is surrounded is hot air, containing a little 
moisture, that the tissues may not experience too great desiccation from its 
contact, and that the softening of the loosened scales of epidermis, which is so 
essential, may be the sooner effected. In this bath, water is not absorbed by 
the skin, as in the Russian vapour bath, or the steam baths of this country ; 
but it is, on the contrary, given out by both the pulmonary and cutaneous sur- 
faces in great abundance. 

"In the Russian bath, as described by Sir George Lefevre, the vapour is 
raised by pouring water over a stove, whilst the American Indian uses for the 
same purpose red-hot stones, covered by the inner bark of oak, and upon which 
a small quantity of water is poured, to prevent too great desiccation ; thus 
resembling the Oriental bath in being a sweating process, while it differs from 
it in the subsequent immersion in cold water, which is not practised by the 
Turks, although cold plunge baths, and even douches, may be found in Egypt, 
in connection with the more essential processes presently to be described. In 
the Western steam bath the vapour is obtained by boiling water externally, 
and is conducted by pipes into the box or chamber which is employed ; but it 
operates on the system rather by virtue of its derivative and sedative action, 
than in consequence of any depurative or diaphoretic effect. All admit the 
advantage of keeping the cutaneous surface in such a condition as may be most 
favourable for elimination of the different substances which are got rid of by 
means of this extensive system of drainage. But it is also worthy of remark, 
that the pulmonary mucous membrane is capable of acting as an excreting 
surface, especially when the body is exposed to the influence of hot air, as in 
the Oriental bath. In this way a large quantity of alcohol and nicotine is 
excreted in those accustomed to the use of spirits and tobacco — the powerful 
odour communicated to the breath betraying the exit of the poison. In ex- 
periments made on the lower animals with phosphorus, this substance has also 
been exhaled with the expired air, the appearance presented in a darkened 
chamber being that of waves of light issuing from the nostrils. Now, while 
this pulmonary transpiration is very much increased in a hot, dry atmosphere, 
it is almost completely checked when the air to be respired is heavily loaded 
with vapour, as is also the case with the functions of the skin. This is what 



1858.] 



Materia Medica and Pharmacy. 



251 



constitutes the most striking difference between the bath of Eastern nations 
and the vapour baths of the West; and it is by no means an unimportant 
difference, inasmuch as the perspiration is intended by nature not merely as a 
means of ejecting superfluous moisture and effete tissue, but also as a natural 
safeguard to prevent the temperature of the body from being raised to an in- 
jurious extent. This safety valve does not exist in the vapour bath ; and in 
using it our very lives may be said to be dependent upon a thermometer ; for, 
evaporation being checked, the temperature of the body may be very quickly 
raised, and accidents are by no means rare from inexperience or carelessness 
in the administration of the different forms of steam baths. People also imagine 
that when in these baths they perspire very profusely, because on going out of 
them they are covered with large drops ; but nine-tenths of these are simply 
the superfluous vapour which has condensed upon the body, and whose pre- 
sence greatly impedes the natural exudation. In the Oriental bath, the small 
quantity of vapour which exists is only that which is produced by the water 
which is spilled on the hot floor during washing, and produces an agreeable 
soothing effect, instead of that suffocating sensation which one experiences in 
the Russian bath, in which, after having been half boiled, you are scrubbed 
with a hard brush, and flagellated with a bunch of twigs. 

"The first chamber which is entered serves as a dressing-room, where the 
clothes are deposited previous to entering the hot chambers, and where the 
bather remains to cool himself on leaving them. For this reason it was called 
the frigidarium by the Romans, although the temperature is about 25° centi- 
grade, or something over the summer heat of our thermometers. The next 
room is about 10° hotter, and is called the tepidarium, where the bather 
reclines, and drinks some hot coffee, or smokes, until he is in a proper condition 
for entering the third chamber, which is only about 5° hotter. I paid particular 
attention to this point when in Constantinople, always bringing my thermo- 
meter into the bath, and in no instance did I find the heat above 40° centigrade 
(104° Fahrenheit). Were it considered necessary, however, an enormous heat 
could be endured in the Oriental bath.' A French gentleman, who was nearly 
suffocated by the vapour of the baths of Nero, near Pozzuoli, in a temperature 
of 122° Fahrenheit, was able to bear a heat of 176° Fahrenheit, in dry air, 
without inconvenience. The floor of the bath being the hottest part, the stratum 
of air next it ascends continually, carrying with it the superfluous vapour, 
which condenses upon the roof, and creates an imperceptible current, which 
suffices to purify the atmosphere. In the third or hot chamber, corresponding 
to thelaconicum of the Spartans, and the calidarium of the Romans, the bather 
is shampooed — a kind of kneading of the muscles ; and the dead skin, with its 
adherent impurities, is removed by means of the goat's-hair glove ; and the 
amount of extraneous matter which is thus collected from the most cleanly 
person, will excite some surprise in those only accustomed to the use of soap 
and water. 

" After the use of the glove the bather is next thoroughly washed with soap 
and hot water, performing part of the washing himself, as he is never naked 
during any part of the bath, the Turks especially being most scrupulous in 
this respect. When he gets up he puts on a pair of wooden pattens, to keep 
his feet off the hot floor, and returns to the second chamber, where he is lightly 
wiped, and again clad with warm towels, the head being bound up to avoid 
taking cold. The bath is now finished, but it would be imprudent to go out 
without remaining some time in the frigidarium to become cool. Here it is 
customary to lie down, well swathed in towels, and to drink some sherbet or 
coffee, and smoke. Nor does the bather require much persuasion to induce 
him to stop, as the sensations are so delicious, that it is only necessary to lie 
still to enjoy a mental calm and exquisite consciousness of health that few of 
us have ever experienced. 

" Here we have a pleasure which is not a vice — a luxury which does not tend 
to shorten life ; and which only awaits a sufficient demand to give encourage- 
ment to capital, that it may become at once cheap and universally attainable. 
There is no drug in the Materia Medica at all comparable with it as a purifier 
of the blood ; for even poisons are thus eliminated from the system ; and it is 



252 



Progress of the Medical Sciences. 



[Jan. 



well known that alcohol is frequently taken by the Turks in large quantities 
without producing inebriation. Besides which, they enjoy an immunity more 
or less complete from various diseases which are here prevalent, and which 
would be quite unaccountable were the influence of the bath to be denied. 
Gout is scarcely known ; rheumatism is rare, and soon cured ; workers in lead 
paints seldom are affected by colica pictonum ; chronic skin diseases are very 
rare, and pulmonary consumption much less common than with us. 

" The Turks are indeed seldom ill, and are, on the whole, longer lived than 
the Western nations, if one may be allowed to judge from the number of old 
men to be seen in the streets, for unfortunately the government keeps no 
statistics. The physicians who have had the most experience in attending 
them are, moreover, of opinion that these happy results are really owing to the 
great attention which they bestow upon the functions of the skin ; and Dr. 
Millinger (the Sultan's physician) informs me that the Turks themselves have 
always considered the public baths of Constantinople as supplying the place 
of a certain number of hospitals, which must otherwise be built. Of the former 
there are 300 open to the public, and every gentleman who can afford it has a 
private one in his own house ; while there are only two or three public civil 
hospitals for a population of 900,000 souls, nor were these at all crowded when 
I was in Constantinople. 

" Facts like these may lead us to inquire whether the office which nature 
has intended for the skin is not really much more important than we are in 
the habit of considering it ; and whether cutaneous respiration be really re- 
stricted to the lower animals. 

" It is an important practical question to the British public to know whether 
the Oriental bath is, in the first place, conducive to health, and, in the second, 
whether it is suitable to this climate. The first of these questions has been 
answered over and over again by travellers who have thus recruited their 
wearied frames, and by the experience of one-fourth of the population of the 
world, who look upon the bath as not merely the greatest of luxuries, but as 
a necessity, without which life would be a burden to them. 

"We may perhaps be told that the bath has been discontinued in the west 
of Europe, because it was found unsuited for the climate and the genius of the 
people ; but history furnishes other reasons to account for its disappearance — 
luxury and depravity did indeed enter the sanctuary, and in the endeavour to 
suppress them, the temple of cleanliness was destroyed. In the time of Con- 
stantine, a regular crusade was waged against them by the clergy, and the 
civil power being placed in their hands almost without restriction, they de- 
stroyed at one fell swoop the two greatest bulwarks by which the physical 
energy of the people had been preserved — bodily exercise capable of acting 
upon the entire muscular system, and a habit of cleansing the entire body. 
Thus fell the baths and gymnasia of Europe. The ancient bath is worthy of 
restoration, both as a hygienic and remedial agent. A beginning has already 
been made, and our native land has taken the initiative ; the only building of 
this kind in the west of Europe being lately opened in the neighbourhood of 
the city of Cork, where it is used as a medical agent, with, I understand, con- 
siderable success. No doubt, further improvements will shortly be made, 
which will render it more serviceable as a remedy, both by additions and 
alterations in its manner of working. I myself have suggested the introduction 
of a certain measured quantity of pure oxygen gas, which may readily be done 
by means of small tubes, whenever that element may appear to require re- 
newal ; and I am not without hopes that I may soon be enabled to bring before 
the profession some further communication upon this interesting subject/' — 
Dublin Hospital Gazette, Sept. 15, 1857. 

13. On the Preparation of Valerianate of Ammonia of Definite Composition. 
— This salt had hitherto not been obtained in a state of purity, and in the solid 
form. In fact, even in the most recent treatises on chemistry, the valerianate 
of ammonia is described as being liquid and amorphous ; and the manufac- 
turers of chemical products have been unable to supply it in a solid and crys- 
tallized state, pure, and of uniform composition. MM. Laboureur and Fontaine 



1857.] 



Materia Medica and Pharmacy. 



253 



have endeavoured to overcome this difficulty. Their process consists in pre- 
paring pure valerianic acid and ammoniacal gas, and then uniting the two 
bodies. In proportion as the combination takes place the salt crystallizes in 
a confused form, but under the microscope, four-sided prisms, either terminated 
in pyramids or bevelled at their extremities, are distinctly seen. The va- 
lerianate thus obtained has been analyzed by a commission of the Academy of 
Medicine, and its purity has been ascertained. 

The following is the formula : Take monohydrated and pure valerianic acid ; 
place it in thin layers in a flat capsule, covered with a perfectly fitting receiver ; 
let anhydrous ammoniacal gas pass into the receiver, until the valerianic acid 
is saturated ; preserve the valerianate of ammonia in small portions, in well- 
stopped bottles. — Bull. G6n. de Therap., torn. 52. 

14. Formula for a Liquor Cinchonas to replace the Wine of Bark. — M. Des- 
champs proposes the following : Alcohol, s. g. 833, five ounces ; water, twenty- 
seven ounces ; sulphuric acid, s. g. 1845, fifteen and a half grains ; yellow bark, 
three ounces; orange peel, four scruples. Macerate the entire for ten days, 
strain, and add to the strained liquor half its weight of sugar; dissolve the 
sugar, and strain. One ounce represents the infusion of half a drachm of bark. 

The advantages of the preparation are said to be, that while it is compara- 
tively cheaper than wine of bark, the sugar it contains will modify its action 
in the same manner as the organic matter contained in wine does ; secondly, 
that its taste is more agreeable than that of wine of bark; thirdly, that the 
preparation will always be uniform ; and fourthly, that children will not refuse 
to take it. — Ibid. 

T5. Formulas for the Gelatinization of Cod-liver Oil. 

M. Stanislas Martin' s Jelly modified. — Take of cod-liver oil, two ounces ; fresh 
spermaceti, two and a half drachms ; simple, or other suitable syrup, and 
Jamaica rum, of each six drachms. Beat the ingredients together with the 
aid of heat, and when the mixture has acquired some consistence, pour it into 
a wide-mouthed bottle. Cod-liver Oil solidified with gelatine. — Take of pure 
gelatine, half an ounce; water, simple syrup, of each four ounces ; cod-liver 
oil, eight ounces ; aromatic essence, as much as may be sufficient. Dissolve 
the gelatine in the boiling water, and add successively the syrup, the oil, and 
the aromatic essence; place the vessel containing the entire in a bath of cold 
water; whip the jelly for five minutes at most, and then pour it, while still 
fluid, into a wide-mouthed glass bottle, furnished with a cork, or with a pewter 
cap, or if a bottle be not at hand, into a porcelain or earthenware pot, which 
should be carefully closed. Cod-liver oil gelatinized with Carrageen or Irish 
Moss. — Take of fucus crispus, half an ounce ; water, eighteen ounces ; simple 
syrup, four ounces ; cod-liver oil, eight ounces ; any aromatic, according to 
taste. Boil the carrageen in the water for twenty minutes ; pass the decoctio n 
through flannel; concentrate it until it is reduced to four ounces by weight ; 
add the syrup, the oil, and the aromatic ; whip the mixture briskly, having 
first placed it in a cold bath, and pour it, while still a little warm, into the 
vessel intended to receive it. The syrup maybe replaced by an equal quantity 
of Garus' elixir, mint, or vanilla cream, or rum, &c. 

M. Sauvan proposes to combine cod-liver oil with Iceland moss. Lichen 
and Cod-liver Oil. — Take of Iceland moss jelly, four ounces ; gelatine, four 
scruples ; hydrocyanated cod-liver oil (to which two drops of essence of bitter 
almonds have .been added), six drachms. Prepare the Iceland moss jelly in 
the usual manner ; melt the gelatine and pass it into the vessel which is to 
hold it ; then add the cod-liver oil ; stir the entire with a spatula, until the 
mixture be homogeneous and the jelly begins to congeal. Dose — two or three 
spoonfuls daily. — Ibid. 

16. Caustic Glycerine in Lupus. — The following formula is employed by Dr. 
Hebra, of Vienna : Iodine, iodide of potassium, of each one drachm ; glycerine, 
two drachms. This is applied every second day by means of a brush ; it pro- 
No. LXIX.— Jan. 1858. 17 



254 



Progress of the Medical Sciences. 



[Jan. 



duces pain which lasts for more than two hours ; but it possesses the great 
advantage of curing lupus without giving rise to disfiguring cicatrices. — Ibid. 

17. On a Mode of Improving Cow's Milk and rendering it more easy of Diges- 
tion for Healthy and Diseased Children. — Dr. Gumprecht, of Hamburgh, re- 
marks that milk often disagrees with children, producing indigestion, acidity, 
flatulence, colic, diarrhoea, &c. &c. In consequence of this, it has been pro- 
posed to improve it by the addition of water and sugar of milk, which experi- 
ence has proved to have imperfectly attained the object in view. Reflecting 
on the effect of salt in rendering the food for adults not only more palatable, 
but also more digestible, increasing the activity of the glands of digestion, and 
rendering the albuminous substances and fat soluble in the fluids of the sto- 
mach, Dr. Gumprecht was led to the idea of adding salt to milk, both for 
weaned and older children, with the result of not only preventing the derange- 
ment of digestion, but moreover of removing them in cases where they pre- 
viously existed. No author who has written on the nutriment of weaned 
children has spoken of this most useful addition to milk ; but a Dutch physi- 
cian mentioned to Dr. Gumprecht, in conversation, that in his practice in Hol- 
land he had frequently added a little salt to milk for weaned children with 
most satisfactory consequences. 

In the rural districts in Holland, salt is frequently added to the fodder for 
pigs and cattle, for the purpose of preventing diarrhoea, which so often exists 
in consequence of imperfect digestion, and this suggested the adding salt to 
milk, not merely for healthy children, but for strumous children and such as 
are affected with worms. Dr. Gumprecht quotes a passage from L. Nussdorff's 
Lehrbuch der Gesundheitspfege, 1856, on the importance of salt in the nutri- 
ment of man and animals. 

With regard to the quantity of salt which should be added to the milk, it 
must depend on the age of the child. To render cows' milk like human milk, 
it should be boiled and skimmed, and a little sugar of milk and salt added. — 
Dublin Hospital Gazette, Oct. 1, 1857, from Journal fur Kinderkrankheiten. 

18. Mode of Preparing the Bran Loaf for the Use of Diabetic Patients. — Mr. 
John M. Camplin gives the following formula for preparing the bran loaf, 
which Dr. Garrod considers the best substitute for bread, for diabetic patients, 
with which he is acquainted: — 

Take a sufficient quantity (say two or three quarts) of wheat bran, boil it in 
two successive waters for ten minutes, each time straining it through a sieve ; 
then wash it well with cold water (on the sieve) until the water runs off per- 
fectly clear ; squeeze the bran in a cloth as dry as you can, then spread it 
thinly on a dish, and place it in a slow oven — if put in at night let it remain 
until the morning, when, if perfectly dry and crisp, it will be fit for grinding. 
The bran thus prepared must be ground in a fine mill, and sifted through a 
wire sieve of sufficient fineness to require the use of a brush to pass it through ; 
that which does not pass through at first must be ground and sifted again, 
until the whole is soft and fine. 

Take of this bran-powder 3 ounces, Troy, 3 fresh eggs, 1J ounce of butter, 
rather less than half a pint of milk; mix the eggs with part of the milk, and 
warm the butter with the other portion; then stir the whole well together, add- 
ing a little nutmeg and ginger, or any other agreeable spice. Immediately 
before putting into the oven, stir in first 35 grains of sesquicarbonate of soda, 
and then 3 drachms of dilute hydrochloric acid. The loaf thus prepared should 
be baked in a basin (previously well buttered) for about an hour or rather 
more. 

Biscuits may be prepared as above, omitting the soda and hydrochloric acid, 
and part of the milk, and making them of proper consistence for moulding into 
shape. 

If properly baked, the loaves or biscuits will keep several days, but should 
always be kept in a dry place, and not be prepared in too large quantities at a 
time. — Med. Times and Gaz., May 2, 1857. 



1858.] 



Medical Pathology and Therapeutics. 



255 



19. 27*e Chemical Properties of the Potato, and its Uses as a general article of 
commerce, if properly manipulated. — Mr. J. AY. Rogers read before the section 
of Chemical Science of the British Association, at its late meeting in Dublin, a 
paper on this subject; the object of which was to show that the matter of the 
potato was in reality equal in nutritive value to the dry matter of wheat, whilst 
the quantum of food produced from a given quantity of land was nearly four 
times that produced from wheat. Mr. Rogers exhibited some interesting 
specimens of the potato in meal, flour, etc. ; and gave the following results of 
analysis : — 

Starch. Gluten. Oil. 

Components of the potato per cwt, 84.0771b. 14.8181b. 1.1041b. 

of wheat " 78.199 17.536 4.265 

And he gave the following important fact as to the quantum of food from an 
acre of land : — 

Starch. Gluten. Oil. 

Drv matter of potato .... 3,4271b. 6041b. 451b. 

of wheat . . . • . 825 185 45 

British Med. Journ., Oct. 3, 1857. 



MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

MEDICINE. 

20. Case of Marshall Hall, with the Post-mortem Appearances. — To render the 
case of this illustrious physiologist complete, it is necessary to go back some 
years previous to the appearance of the last severe and fatal symptoms; for 
some peculiar features connected with the earlier symptoms rendered the case 
somewhat different to those generally met with in practice, and made the suf- 
ferer himself, always patient, thoughtful, and suggestive, consider that it pre- 
sented features worthy of notice; and also made him anxious that its investi- 
gation should be completed by a post-mortem examination. 

His own account of an early inconvenience or difficulty in swallowing best 
explains the symptoms as they occurred : " Some fifteen years ago," he wrote 
to a friend, " I undertook to deliver two long and distinct courses of Lectures on 
the Practice of Physic, during the same winter." His custom was to lecture 
from six to seven, and then from eight to nine, in the same evening. He felt 
inconvenience during this winter from hoarseness and cough for the first time, 
and began to perceive that minute portions of food were apt to remain in his 
pharynx, and that after meals he occasionally raised some small portions. This 
difficulty of swallowing very gradually appears to have increased ; and he was 
induced, some years ago, to consult Sir Benjamin Brodie and Dr. Chambers 
on account of the increasing symptoms of obstruction; but on Sir Benjamin 
passing a bougie, no evidence of obstruction by contraction of the oesophageal 
tube could be detected. Mr. Guthrie, whom Dr. Marshall Hall also consulted, 
told him that he was only suffering from what was called " clergyman's throat." 
But the dysphagia continued, and during deglutition much care was requisite 
in the act of swallowing, and food could not be hastily taken, and while in the 
act of swallowing much regurgitation could be heard by those sitting near 
him. 

He considered this condition to be due to a defective reflex action which pre- 
vented the muscles of the pharynx from acting with sufficient power to propel 
all the food lodged in it ; but the probability is, that there was some such dila- 
tation of the pharynx at this early period as is sometimes met with, and which 
in a measure acts upon the aperture of the oesophagus mechanically, and thus 
interferes with the ready passage of food. Such were the symptoms which 
continued slowly increasing, but which never prevented a sufficient amount of 
food to be taken, both solid and fluid, to keep up proper nutrition, until about 
the end of 1855, when Dr. Marshall Hall first perceived that in the expectora- 



256 



Progress of the Medical Sciences. 



[Jan. 



tion which he usually had in the morning there was occasionally a slight tinge 
of blood, and this especially after much speaking or exercise. The dysphagia 
also commenced from this time to be troublesome and serious. 

Previous to this date Dr. Marshall Hall had retired from active practice in 
London, as he found his health was failing to a certain extent, and some spots 
of purpura appearing on his legs. He wisely determined at once to give up 
the anxieties of professional occupation, though it entailed the sacrifice of a 
large professional income. He made a tour of the United States in 1854-55, 
and spent the following winter and spring in Italy. He returned to England 
much better in health, but not improved as far as the throat affection was con- 
cerned. After a short stay in town, he went to Hastings, and came to town 
again in October following. It was now that the symptoms of permanent 
stricture of the oesophagus were fully established. He had some time ceased 
to partake of solid food ; milk, cream, and coffee were the fluids he chiefly 
preferred. With the evident obstruction there was constant copious expectora- 
tion of purulent mucus, somewhat offensive in character, and occasionally dur- 
ing each day tinged with blood. He was seen in consultation by Dr. Williams, 
Mr. Caesar Hawkins, Mr. J. R. Martin, and Mr. Pollock, all of whom were 
agreed as to the serious nature of the complaint. He was quite prepared for 
the expression of their most unfavourable opinion, and was even cheerful whilst 
under examination. In speaking to one of his medical friends, who was con- 
stantly with him whilst in town, he said, " I don't ask you what your positive 
opinion is as to my prospect of life, for no one can be certain of the result of 
a hidden malady; but I look upon my disease as a fatal one, and have long 
done so. I have no hope of recovery. I don't wish you to mention this to 
Mrs. Hall. I have no fear of death, and cannot be alarmed by the truth. My 
only wish to live is for the sake of others ; but I am resigned to the alternative, 
if it be ordered that I should not live much longer." The calm, resigned, and 
almost cheerful manner in which he spoke at once showed the preparation and 
the courage of a man who knew his end was not far distant, though still, as 
ever, unselfish, considerate, and affectionate, for those dear and near to him. 

Whilst in London he had a wish to have the nitrate of silver applied in solu- 
tion to the supposed ulcerated part of the pharynx ; but when advised not to 
employ it, he readily acquiesced in the opinion of those he had consulted. He 
had applied the solution to the throat when in the country, but had been ap- 
parently much distressed by it ; and though he had expressed a wish for its 
application a second time, he evidently had no great desire to persist in its use, 
from the distress it had occasioned. 

After a short stay in London he removed to Brighton. He now placed him- 
self under the care of Mr. Wildbore, whose constant care and attention to him 
he always spoke of with much gratitude, and to whose note-book we are in- 
debted for the remaining particulars of his case. 

After being settled in Brighton, he complained of, and suffered much from 
cold. It always distressed his throat, and rendered more difficult the efforts of 
swallowing. His room was obliged to be kept at a temperature of from 70° 
to 75° ; his diet was entirely milk, cream and coffee. In January this year he 
wrote to Mr. Pollock : " I have been for two months at Brighton, and the com- 
plaint has made no progress, but in cold foggy weather my dysphagia is always 
worse. I am intensely susceptible to cold. I have been many days lately 
without blood in the expectoration ; but last night it came on after going to bed, 
without any assignable cause. Everything I take is apt to leave particles in 
my pharynx, even a light-boiled egg. Hence the cause of the irritation and 
consequent ulceration there. If so slight a thing will irritate and produce ex- 
udation of blood, there is surely ulceration there, and this, in fact, has all 
along been my opinion." We shall hereafter see how true was the opinion he 
had formed of his own case. 

There was at all times, to a greater or less degree, " a stinging, bursting 
pain" behind the larynx ; sometimes for a day or two it was absent. During 
February the symptoms were variable, the dysphagia increasing as the tempera- 
ture became colder. Once or twice there was slight regurgitation of the fluid 
by the nose and mouth. Some considerable benefit was derived from sipping 



1858.] 



Medical Pathology and Therapeutics. 



257 



a solution of chlorate of potash in water several times a day, with marked 
temporary benefit to the swallowing, but the effect was not permanent. 

In March he had a severe attack of gout, when much uric acid passed in 
the urine. This was relieved by small doses of potash sipped in water, and 
also used in an enema. The dysphagia slowly but gradually increasing, four 
pints of milk were now only taken in the course of the day, and it occupied 
nearly half an hour to get down half a pint. 

On the 10th of March he walked out, after four months' confinement to the 
house. The sun was hot, but the wind very cold, and the following day he was 
confined to bed, suffering from bronchitis, and all his ordinary symptoms aggra- 
vated. During several hours no fluid could be swallowed, and on attempting 
to pass a tube for himself, an obstruction was met with, opposite, as he said, 
the first or second portion of the sternum. This attack left him very weak. 
He complained much of thirst, and said his feelings of hunger were dreadful. 
Still he was most patient, and even cheerful in conversation, under all his suf- 
ferings. 

In a few days the attack of bronchitis passed off, and he now derived much 
comfort from supping iced milk and sucking small pieces of ice ; but the ex- 
haustion and emaciation were becoming considerable, and the quantity of fluid 
taken by the mouth was reduced to about two pints in the twenty-four hours. 
Mr. Wildbore therefore recommended him to allow the administration of nutri- 
tious enemata, of which the following was the mixture ; five ounces of strong 
beef tea, one ounce of port wine, and three grains of quinine. This was given 
three times daily, and the whole quantity always retained. The quinine was 
added on account of his suffering from intermittent fever which came on every 
night. The enemata were evidently absorbed, for the bowels only acted once 
in three or four days under the influence of warm water enemata, with some 
salt dissolved in it, and this would be followed by a healthy motion. 

On the 10th of April, for twenty-four hours, there was complete interrup- 
tion to the passage of fluid through the throat; but on the following day he 
was again able to swallow milk and some wine-and-water. Towards the end 
of the month the difficulty of swallowing was so great, that if more than three 
teaspoonfuls were taken directly one after the other, the fourth would bring on 
cough, and the greater portion would be returned by nose and mouth, mixed 
with mucus, as if the fourth spoonful filled up the tube to the aperture of the 
glottis, and thus excited cough. 

During the month of May he suffered much from hunger; but taking the 
enemata four and five times a day appeared to nourish him to the extent that 
he was able to bear the erect posture, which he could not a fortnight previously, 
owing to vertigo. The aguish attacks were also severe, and he took constantly 
about twenty grains of quinine in the enemata, which had the effect of relieving 
him, but produced deafness and singing in the ears. 

In June the voice began to be affected; the expectoration, which had become 
white and frothy, was again purulent and offensive. The efforts to swallow 
were attended with much exhaustion, and the struggles to get fluid down were 
very great. The loss of voice at the end of June was unchanged ; the "sting- 
ing, burning pain" greater, and debility increasing; the expectoration very 
copious. Notwithstanding his condition, about the middle of the month he 
ate a fair dinner of lamb and asparagus for three or four days consecutively, 
swallowing it all. Then came a cold wind and increased dysphagia. 

In July, early in the month, he applied himself a four-grain solution of nitrate 
of silver to the pharynx five times. This increased the u stinging, burning 
pain " greatly for two hours after each application, but no beneficial result of 
any kind was obtained. Chills and profuse sweats attacked him every evening, 
and the aphonia continued. During July he gradually became weaker, and 
the quantity of fluid taken by the mouth was about a pint to a pint and a half 
of milk daily. It may be mentioned that nearly all the time he was at Brigh- 
ton, up to the last few days of his life, he looked fresh and healthy, a circum- 
stance somewhat remarkable. 

By his own desire he went out, in the early part of August, in an open car- 
riage, but all his symptoms were becoming worse : the breathing short and 



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[Jan. 



asthmatic, and the air-passages clogged with mucus. The rectum also became 
uncertain in its powers of retention, and the enematawere sometimes returned. 
On August 11th, at twenty minutes past eight, he died, maintaining his con- 
sciousness to within a few minutes of his death. 

His friend, Mr. Wildbore, wrote of him, but a few days before his death, 
" It is wonderful to me how he bears up against his disease. He is ever thought- 
ful of, and kind and considerate to all around him, and most grateful for the 
least kindness or attention shown him ; always interested in professional ques- 
tions, and ever active in mind upon those subjects which have chiefly occupied 
his attention. He is most patient, and perfectly resigned." All who knew 
and watched him during the progress of his disease, and witnessed the high 
courage and true resignation with which he submitted to his sufferings and to 
the prospect of death, will feel that Mr. Wildbore's estimation and record of 
him was only what was just to the character of the greatest of English physi- 
ologists. 

The post-mortem examination of the body was made by Dr. Ransom, of Not- 
tingham, thirty-eight hours after death, in the presence of Dr. Hutchinson, 
Dr. Robinson, Dr. T. Wright, Mr. Higginbottom, Mr. Addison, Mr. Wildbore, 
and Mr. M. H. Higginbottom, and for the record of which we are indebted to 
Mr. Ransom. 

The body was emaciated. No external marks of decomposition. 

Thorax. — The lungs did not collapse on the cavities being opened. The right 
one was universally adherent by old adhesions ; the substance of the lungs 
healthy; no pleuritic effusion. 

The pericardium contained nearly two ounces of dirty red fluid. The heart 
was flabby (perhaps from cadaveric changes) ; it contained frothy blood in the 
right ventricle and auricle. The valves were competent. There were some 
atheromatous deposits on the inner surface of the aorta, which was stained a 
deep red. 

The bronchial glands were larger than usual, soft and black. 

On making examination of the parts higher up in the throat, it became evi- 
dent that some undue thickening and adhesions existed behind the larynx. 
The latter was therefore removed, with the pharynx, the oesophagus and trachea. 
In doing this, the intimacy of the adhesions necessitated that the knife should 
be carried close to the bodies of the corresponding vertebree ; with every care, 
however, buttonholes were made in two or three places. On removal, it was 
seen that the walls of the pharynx were extremely thin, and that its cavity 
was dilated. Through the openings made by the knife there escaped a dirty- 
brown flaky fluid, of a creamy consistence. The adhesions were to the bodies 
of the sixth and seventh cervical and first and second dorsal vertebra3. 

The parts removed, when examined, showed a stricture of the oesophagus, 
about the level of the eighth ring of the trachea, and a dilatation, with ulcera- 
tion and vasculation of the oesophagus and pharynx above the stricture, to the 
extent of nearly three inches. The stricture was attended with but moderate 
thickening of the tube, and the aperture was not very small; but the mem- 
brane was folded in, so as to present a conical eminence upwards, the apex of 
which was opposite the narrowest part of the stricture, which here was rather 
larger than a goose-quill. In this way the passage was almost valved, and 
food would have had the tendency to pass down by the sides of the eminence 
into the pouches and sacculi of the ulcerated portion. Indeed, the finger 
passed down from above, previous to opening the oesophagus, could not enter 
the passage, though a similar difficulty did not exist if the finger was passed 
from below the stricture. The upper border of the ulceration was, on each 
side, about level with the bases of the arytenoid cartilages, but did not extend 
so high in the middle. The dilatation was, throughout, irregularly ulcerated, 
soft, pulpy, ragged, of a dirty-gray or slate-coloured, and with few loosely-ad- 
hering flakes on its surface. Its base was not much thickened, though here 
and there it was somewhat so, and felt firmer in such parts. The walls of the 
pharynx and oesophagus were perforated in several places, leading to pouches 
or sinuses amongst the muscles of the neck, having very thin delicate walls of 
false membrane. Two of these pouches were very large, and ran upwards on 



1858.] 



Medical Pathology and Therapeutics. 



259 



the outer surface of the thyroid cartilage, one on each side, as high as its upper 
border, the right pouch being the largest. A narrow slip of mucous membrane 
remained at the back of the trachea, but this at the lower extremity was quite 
undermined. 

At the lower part of the dilatation the ulceration had nearly perforated the 
trachea through the posterior membranous wall, and had set free the right 
extremities of the fourth, fifth, and sixth cartilages. The pharyngeal mucous 
membrane above the ulceration appeared nearly natural, except for two or 
three little rounded elevations, as if there was a deposit in the mucous mem- 
brane, each less than half a pea in size. There was a small pendulous polypus 
attached to the thyro-epiglottidean fold. The oesophagus below the stricture 
was healthy. 

In the mucous membrane of the trachea directly corresponding to the deep 
ulceration that threatened to perforate it, was a small deposit or growth — semi- 
transparent, solid, and slightly elevated. There was a similar one higher up, 
inside the cricoid cartilage, but it was more opaque and white. 

The patch on the tracheal mucous membrane was cut across, and from a 
section of it were obtained cells which possessed all the characters of cancer- 
cells. They were delicate, large, irregularly angular, with elongated processes ; 
some were, however, rounded, had peculiar large nuclei and nucleoli ; often 
several of these in one cell, and sometimes a cell-wall around one or more of 
the contained nuclei. Some few of the nuclei presented a delicate, regular 
radial striation, which Dr. Ransom observes he had not before seen. These 
cells were contained amongst the meshes of the elastic tissue. From the whiter 
patch on the inside to the cricoid cartilage, similar cells were obtained, but 
they were fattily degenerated, and therefore less characteristic. From the base 
of the ulcerated surface Dr. Ransom found in parts examined no satisfactory 
evidence of the nature of the pathological process which had preceded ; but 
amongst a mass of granular and fattily degenerated elements, several bodies 
were always seen resembling retrograde cancer-cells. 

The fluids from the surface of the ulcer consisted mainly of molecular detri- 
tus and fat, in drops and granules, with a great number of epithelium scales, 
mostly of the scaly variety ; but a few were cylindrical and ciliated, probably 
separated from the upper parts of the pharynx. In the little elevations on the 
mucous membrane of the pharynx nothing was found but globular corpuscles 
and cells filled with fat granules of various sizes ; and one beautiful hexagonal 
crystal-like cystin was observed. 

A portion of the pharynx and oesophagus, examined by Mr. Caasar Hawkins, 
Mr. Pollok, and Mr. Holmes, curator of St. George's Hospital Museum, gave 
the following results : — 

1. A portion of the disease was surrounding the great vessels in the neck, 
and apparently making pressure on the upper part of the pharynx. The in- 
terior appeared of a cellular character. Sections showed fibrous tissue, with 
numerous nuclear bodies, and much fat. 

2. A small tubercle, beneath one of the rings of the trachea, contained an 
immense number of nucleated cells, resembling those of healthy epithelium, 
but of more curious form and size ; also a good deal of fat. 

3. A mass containing dark masses (of black pigment), otherwise exactly 
resembling the portion first mentioned. 

21. Hanmopliilia. By Dr. Magnus Huss. — This term was first employed by 
Grandidier-to designate that peculiar tendency to hemorrhage which charac- 
terizes some individuals and families. The following case, which is reported 
and commented upon at length by the well-known Professor Huss, of Stock- 
holm, is almost unique of its kind. 

Maria K., a servant, aged twenty-three, a country girl, the child of labouring 
people who had always enjoyed sound health, and exhibited no hemorrhagic 
tendency or other hereditary taint, was admitted into the Seraphim Hospital 
of Stockholm, January 16th, 1851, of good complexion, healthy looking, and 
well built. Catamenia appeared without abnormal features at the age of fif- 
teen ; had never been ill, excepting convulsive fits in her infancy ; there had 



260 



Progress of the Medical Sciences. 



[Jan. 



been do remarkable tendency to hemorrhage, but whenever she had met with 
an injury the parts had cicatrized as in any other person. She went into 
service when nineteen years old, and was maltreated on the 4th August, 1850. 
She was severely buffeted, and struck about the head, in consequence of which 
she was much excited and seized with convulsions, during which she screamed 
and struck her head against the surrounding objects ; she was insensible for 
about half an hour. On recovering herself she found that she had bled pro- 
fusely from the head, without being able to find any lesion of continuity. She 
continued in a torpid state during the succeeding three days; she merely re- 
members that the hemorrhage persisted, and that blood also flowed from the 
eyes, the left ear, and that she vomited blood. She continued very feeble after 
this time, the hemorrhages recurring almost daily. They ceased after two 
months, when she recovered her health for a fortnight ; without any cause, the 
hemorrhage then returned one night from the cranium, and at the same time 
she vomited coagulated blood. The hemorrhage from the cranium continued 
for a week, then stopped, and the patient was well for two months. After 
that, the hemorrhage recurred every eight or fourteen days from the cranium, 
eyelids, and left ear. When examined after her admission, no traces of a pre- 
sent or previous solution of continuity could be traced on the cranium ; there 
was no trace of injury to the bones. The hemorrhagic attacks continued to 
occur on the slightest emotion, but without special symptoms, except on one 
occasion, when, at the commencement of copious hsematemesis, the patient was 
seized with violent delirium, then lost consciousness, and remained for eight 
days in a state of profound torpor. She then woke up, and the two left ex- 
tremities were slightly paralyzed, and their sensibility somewhat blunted. 
After the lapse of three weeks these symptoms had entirely disappeared. 

In March, 1852, she is described as being anaemic, pale, somewhat emaciated, 
and depressed, but the functions otherwise in normal condition ; the kidneys, 
liver, sexual, and other organs apparently healthy ; emotion so directly influ- 
enced the occurrence of the hemorrhage, that the patient by entering into a 
dispute could generally produce it at will. When it took place, she felt so 
fatigued as to be forced to lie down ; the hemorrhage occurred on each side of 
the coronal suture, on a space three centimetres by ten. The blood was seen 
to sweat out at the roots of the hairs, first forming a red point, which gradually 
augmented to a drop which coalesced with others; if wiped off, the surface 
would soon be again covered with blood ; its colour was that of arterial blood. 
Examined by a lens, no lesion could be detected, but the blood could be seen 
issuing from the hair follicle ; the root of the hair was not diseased. The 
hemorrhage lasted from a few hours to two or three days ; the skin of the 
bleeding part was not tumefied, but slightly tender, and its temperature ele- 
vated. The attack was generally preceded for one, two, or three days, by a 
sense of weight on the head and vertigo, with a feeling of heat and pulsation 
at the spot immediately before the bleeding occurred. Hsematemesis and 
bleeding at the left ear were only occasional concomitants of the attacks ; but 
the former was always accompanied by stupor, alternating with delirium. 

The treatment, which consisted in the administration of tonics and astrin- 
gents of all kinds, with nutritious diet, only caused temporary arrests of the 
hemorrhage. Strange to say, that in spite of the peculiar tendency to hemor- 
rhage from certain parts, there was no predisposition to it from others, for 
contusions and solutions of continuity were not followed by unusual hemor- 
rhage. On the application of local astringents to the head, such violent 
symptoms of cerebral congestion were manifested as to render venesection 
necessary. 

All treatment failing, the patient was sent home in the same state in which 
she was admitted. The details of this interesting case are followed by an 
analysis of the theories applicable to the hemorrhagic tendency, and Professor 
Huss arrives at the conclusion that it is due to spasmodic contraction of the 
veins passing from the capillary network of the parts, in which this form of 
hemorrhage was manifested. — Brit, and For. Med.-Chirurg. Review, Oct., 1857, 
from Archives Gen., August, 1857. 



1858.] Medical Pathology and Therapeutics. 261 

22. On some of the Prevalent Errors in relation to the Predisposition to Hys- 
teria. — M. Briquet believes that most writers have been indebted more to their 
imagination than to the observation of facts for the pictures they have drawn 
of this disease. It has been attributed, by most of them, either to unsatisfied 
sexual desires or to excessive excitement of the uterus and its appendages, and 
a fanciful etiology to correspond has been invented. The object of this paper 
is to show that these and other preconceived ideas have no solid foundation in 
fact. 

1. The hysterical constitution, about which so many positive assertions have 
been made, has, in fact, no existence, the affection occurring in women having 
the most opposite external appearances. The author examined 425 cases of 
hysteria in this point of view ; of these, as regards height, 127 were tall, 168 
medium size, and 106 short; as to strength, 99 were strong, 36 medium, and 
26 weak ; as to flesh, 194 were stout, 106 medium, and 92 thin and spare; as 
to colour, 220 were fair, and 164 dark, 27 having the hair light, 39 black, 177 
light chestnut, and 188 deep chestnut. In 168 the face was pale or brownish, 
and in 174 fresh coloured. Thus it will be seen these were the ordinary varie- 
ties met with among women in general. 

2. The temperament is also various enough. The following is the classifica- 
tion M. Briquet made of 383 cases. In 143, it was lymphatico-sanguineous, 
in 125 lymphatic, in 91 nervous or lymphatico-nervous, in 12 bilious, and in 
11 sanguineous. These are evidently very much the proportions that are found 
in females of from 15 to 30, part inhabitants of the country, and part of the 
towns, as was the case with these. At all events, there is no temperament that 
can properly be called hysterical. 

3. Moral Disposition. — That which is not discoverable in the physical consti- 
tution of hysterical females is, however, very evident in their moral disposition. 
So much is this the case that, of 430 cases occurring to the author, not more 
than 20, at the utmost, have not manifested it. The characteristic of this is 
marked impressionability, foreshadowed in childhood by great timidity, exces- 
sive susceptibility to blame, and a disposition to shed tears easily. 

4. Mode of Life. — Another of the axioms that has been laid down as 
undoubted, is that hysteria is the prerogative of the wealthy and luxurious, 
and that poverty is a security against its occurrence. It is a complete error: 
the common people being the subjects of hysteria in almost a double propor- 
tion to the other classes. At a particular epoch, M. Briquet visited all the 
female patients in the medical and surgical wards of La Charite, with the 
exception of those suffering from epilepsy, apoplexy, insanity, or delirium. 
The number amounted to 203, and of these 65 were hysterical (38 with convul- 
sive paroxysms), 49 were impressionable, and 89 only were, neither hysterical 
nor impressionable. Thus, among the common people, there was 1 woman in 
5 who had hysterical paroxysms, and 3 out of every 8 were the subjects of hys- 
teria. So far from being exaggerated, the statement is rather below the truth. 
But where is the practitioner who meets with 3 cases of hysteria among 8 of 
his private patients? According to the experience of many M. Briquet has 
consulted upon the subject, there is about 1 in 8 or 10 in the easy classes of 
society, not alluding to the very highest. The charms and simplicity of a 
country life, too, have been sufficiently praised, and nervous diseases have been 
said to be the almost exclusive affliction of civic life. M. Forget, in 1847, some- 
what startled this belief by showing how frequently hysteria occurs among the 
simple Alsatian peasantry. M. Briquet has obtained cognizance of the place 
of abode, and' of early education, in 324 cases of hysteria, and of these, 168 
were town-born and bred, and 156 from the country, the majority of these latter 
having, in childhood, laboured in the fields. In the case of 42 of these country 
girls, their mothers had been hysterical, 29 suffering from paroxysmal attacks. 
Professor Lebert, of Zurich, also assures the author that hysteria is just as 
often seen in the poverty-stricken cantons of Switzerland as in the most flourish- 
ingones. A too tender and luxurious education has been assigned as a predis- 
posing cause ; but of 81 cases of hysteria occurring before the age of puberty, 
in 21 the harsh treatment they had been subjected to was the principal cause 
of the disease. A third portion of the author's collection of cases had been 



262 



Progress of the Medical Sciences. 



[Jan. 



submitted to ill-treatment or privation during childhood. In place of a tender 
education being assigned as a predisposing cause, it would be more just to thus, 
stigmatize a harsh one. 

5. Continence has been stated by many authors as an unnatural condition, 
predisposing to hysteria; but when it is remembered that the majority of cases 
occur between 12 and 20, we naturally ask at what age it becomes unnatural, 
as also for the explanation of the occurrence of the disease in 86 children under 
11 years of age. Various authors since the time of Galen have deplored the 
fate of widows, as the necessary victims of hysteria : but, in point of fact, their 
solicitude has been little needed, inasmuch as among 375 cases collected by 
Landovzy, only 12 of the subjects were widows, as were only 14 in the author's 
own 430 cases, i. e., 26 in 800 cases, or 1 in 30. Of the author's 14 cases, too, in 
6 the hysteria appeared on the day of the husband's death, and in 4 during the 
first month after it, and should surely, with more probability, be referred to moral 
emotion. Hysteria has been said to be, on the one hand, common among nuns, 
and, on the other, rare among women who give free vent to their sexual desire. 
But, in point of fact, it is rare in convents, and is chiefly found in those in 
which there is great fasting and maceration. The reverse position so strongly 
maintained by authors may also be disposed of. Thus, of 300 hysterical 
females, above the age of 15, 139 were married or kept women, and among 
them had 367 children, not counting miscarriages. Among the 161 remain- 
ing, very few resigned themselves to continence. At the Lourcine, where 
syphilitic work-women and servants repair, among 424 patients, 169 were hys- 
terical. As to prostitutes, of 197 applying to St. Lazare, on account of syphilis, 
106 were hysterical, 28 very impressionable, and 65 neither hysterical nor im- 
pressionable. It results, from all this, that continent women are rarely hys- 
terical ; those who do not observe continence are frequently the subjects of 
hysteria; while those who pursue the extreme of incontinence are the most 
liable of all. The reason is obvious. Among these different classes of women, 
the first lead peaceable lives, the second have much to go through, while the 
last are a prey to frequent and violent emotions. Next, we may consider the 
effects of marriage on hysterical women, which, to judge from the statements 
made, have been truly remarkable. But, among M. Landovzy's and the author's 
800 cases, in only 29 instances did decided advantage follow marriage, notwith- 
standing the complex character of the modification ensuing upon this state. 

6. Menstruation and Affections of the Uterus. — This class of influences has 
been raised to the highest rank by those writers who are determined at placing 
the seat of hysteria in the uterus. 1. This has been supported by the supposed 
effects of normal or abnormal conditions of the menstruation. From the 
author's observations, however, made on 411 hysterical women, in but 136 had 
there been any derangement of the menses. Of 237 deliveries of hysterical 
women, in but 12 were there any convulsive paroxysms, some of which, too, 
might have been examples of eclampsia. 2. According to authors, it is com- 
mon to observe hysteria in affections of the uterus. Now these diseases are 
exceedingly common, and the connection ought to be easily demonstrable. But 
this is not the case, for Landovzy, and other partisans of the opinion, are able 
to collect but some 40 cases of affections of the genital organs giving rise to 
hysteria: few enough as compared with the thousands of cases daily occurring. 
Practitioners, moreover, having much to do with the various female diseases, 
entirely deny such connection. — Med. Times and Gaz., Oct. 31, 1857, from Union 
MSdicale, Nos. 36, 39, 40. 

23. Asphyxia of Submersion. — Mr. A. T. H. Waters, from a series of experi- 
ments instituted with the view of investigating the two following questions — 
1st. How long the heart continues to beat in asphyxia produced by submersion ; 
2d. What effect the hot bath produces on an animal asphyxiated by submersion 
— arrives at the following conclusions: — 

1. That in dogs and rabbits, when asphyxiated by submersion, the ventricles 
of the heart do not, as a rule, cease to contract " in a few minutes after the ces- 
sation of the functions of animal life;" but that in many instancestheir action 
continues for a very considerable period, and that in all probability the same 



1858.] 



Medical Pathology and Therapeutics. 



263 



remark applies to man, and serves to explain how recovery has taken place 
after lengthened submersion. 

2. That the effects of the hot bath are, to produce great congestion of the 
lungs, and a tendency to coagulate in the blood ; its use becomes thus directly 
prejudicial; that it does not excite respiratory efforts, and prevents artificial 
respiration being properly carried out; and it becomes thus indirectly pre- 
judicial. 

With reference to the treatment of asphyxia, from whatever cause, all our 
efforts should be made to excite respiratory movements, and if these movements 
can be produced before the heart has ceased to beat, there is great probability 
of animation being restored ; and even should the action of the heart have 
ceased, it is possible that by re-exciting respiration we may reproduce the cir- 
culation. 

In attempting to produce artificial respiration, the best method is that recom- 
mended by Marshall Hall. Experiments on the dead body, and numerous 
instances of recovery from asphyxia attest its value, and prove it to be the 
most simple and efficacious means we know of. If artificial respiration be 
attempted when the body is supine, the tongue should be drawn forwards and 
kept so ; this has not been sufficiently attended to. 

The rules for restoring suspended animation recommended by the Humane 
Societies are defective. Their object is to restore circulation and warmth by 
means of the hot bath and hot air, neglecting, or only imperfectly carrying out, 
artificial respiration, on which alone safety depends. Moreover, the directions 
involve very serious loss of time. Few, if any, instances are recorded by these 
societies in which animation has been restored by the means recommended 
after a submersion of more than five minutes — a fact not to be wondered at 
when we consider what these means are. — Liverpool Medico- Chirurgical Journal, 
July, 1857. 

24. Asiatic Cholera and its Prevention. By Henry McCormac, M. D. — As 
physician to the Belfast Cholera Hospital, I had unusual experience in the 
treatment of Asiatic cholera. During the earlier outbreaks of this malady, 
opium and calomel were among the remedies most confided in. During the 
more recent outbursts, however, a new and additional remedy of great efficacy 
was resorted to. This remedy consisted of the dilute acids, any of them. Use 
and convenience gave the preference to dilute sulphuric acid, and to this dilute 
acid, more or less combined with opiates, I habitually restricted myself. The 
name of the person who introduced this remedy, like that of many another 
benefactor of his species, is unknown. The elixir of vitriol, which is merely 
sulphuric acid diluted with spirit, and the addition of a little aromatic is, in 
respect of cholera, in very many cases, literally and truly the elixir of life. 
Twenty drops, in a little water, may be taken every time the bowels are affect- 
ed, also every two hours, for some hours after. But dilute sulphuric acid — 
that is to say, sulphuric acid one part, water seven parts, has precisely the 
same medicinal properties. Here, thirty drops in a little water, will be an 
expedient dose. To children, two drops for each year of the child's life may 
be given. Otherwise the mode of exhibition is the same. 

I now come to another feature in respect to the efficacy of dilute sulphuric 
acid. I find that it possesses preventive, as well as curative properties. On 
the occasion of the outbreak of cholera in the Belfast District Lunatic Asylum, 
and after many deaths had ensued, I put the whole establishment on a pro- 
phylatic or preventive regimen. I added dilute sulphuric acid, in the pro- 
portion of half an ounce of dilute sulphuric acid to twelve ounces of water. 
Of this mixture I caused one tablespoonful, further diluted with a little water, 
to be swallowed each morning by every inmate. Very soon after, the cholera 
had completely disappeared. There is here the alternative of supposing that 
the disease spontaneously vanished, or that the dilute sulphuric acid had acted 
as a prophylactic. I myself prefer the latter conclusion. It is reasonable to 
conclude that a substance which possesses the property of constipating the 
bowels, should be adverse to the propagation of cholera. Now, dilute sul- 
phuric acid possesses this property. It is also conformable to the efficacy of 



264 



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[Jan. 



prophylactic measures generally, though greatly exceeding the efficacy of most 
in the prevention of disease. Sulphuric acid is as cheap as it is effective. A. 
pound of strong sulphuric acid, costing one penny, will make seven pounds of 
dilute sulphuric acid, which, further diluted, would furnish a prophylactic 
draught to the whole of a regiment. And this brings me to the object and in- 
tent of these remarks. They are intended to serve our suffering countrymen 
in India, engaged with a murderous enemy, and assailed by cholera, equally 
murderous. It is of great moment to cure disease, but it is yet more momen- 
tous to prevent it. I, therefore, have recourse to the wings of the press in 
order to disseminate a suggestion, which, if acted upon, I feel assured is cal- 
culated to avert many a pang, and in the East, as well as elsewhere, rescue 
lives of priceless value. 

25. Nature, Causes, Statistics, and Treatment of Erysipelas. — The Midland 
Quarterly Journal for May last, contains a highly interesting paper on this sub- 
ject by Peter Hinckes Bird, F. R. C. S. The following are his conclusions: — 

1. Erysipelas is merely an example on the skin of that diffuse inflammation 
which, in other tissues, constitutes diffuse inflammation of the mucous mem- 
brane, diffuse phlebitis, puerperal fever — all of which have a common origin, a 
poison in the blood, are infectious and contagious, and may mutually produce 
each other. 

2. The term erysipelas should be confined to diffuse inflammation of the skin 
and subcutaneous cellular tissue. 

3. Erysipelas is best treated by stimulants and support, and when compli- 
cated with inflammation of the subcutaneous cellular tissue, by early incisions 
which should extend to the depth of the disease. 

26. Action of Cod-liver Oil in Chest Diseases. — Dr. E. Smith read a paper 
on this subject to the Medical Society of London (Oct. 31, 1857). The object 
of the paper was to show that, whilst cod-liver oil is a valuable remedy, it acts 
simply as a fat with certain physical qualities, and may be, and ought to be, 
supplanted by the ordinary fats used as food. 

He first considered the chemical constitution of the oil, and then the state of 
system existing in phthisis, and particularly entered into an inquiry which he 
had instituted upon 500 cases as to the appetite for the various fats in food, and 
the appetite for, and effects of, the oil. He found that there was a diminished 
appetite for fat in phthisis, but that in no case was the dislike absolute ; and 
in all some kinds of fat could be taken when others were rejected. Thus, fat 
meat was taken by more than half of the patients, and bacon fat by two-thirds ; 
whilst suet in puddings, butter, and milk, were taken by more than nine-tenths 
of the whole. Afterwards, he stated the result of the effect of cod-liver oil upon 
150 in-patients, and proved that in nearly half of them the oil was rejected or 
of no real service. Of 83 who reported themselves benefited, by far the larger 
proportion referred the good effect to improved assimilation ; whilst of 67 who 
were unable to continue its use, or who were not benefited, the ill effect was 
referred to sickness and other circumstances connected with the first acts of 
digestion. After thus showing the degree of good and harm resulting from the 
oil, and the degree of appetite for, and dislike of, fat of various kinds in food, 
he proved that in the large majority of cases there was an appetite for fats 
when oil did good, and the contrary when it did harm, but this was not uni- 
versal ; and he also proved that in the very cases in which the oil was rejected 
there was always appetite for some kind of fat food, and in some cases even for 
the fat of meat. Hence he proved that there was no ground for the assertion 
that the oil was more easily digested and assimilated than some of the natural 
fats in food. The inquiry and medical testimony now prove that cod-oil acts 
beneficially as a nutrient ; and he affirmed, from special experience, that the 
oil has no advantage over the fats in food, provided an increased quantity 
be taken of such of the nutrient fats as the patient can eat. Hence he urged 
the profession to distinguish properly between food and physic ; and, if the oil 
is administered as a nutrient, to inform the patient that it is given as food, or, 



1858.] 



Medical Pathology and Therapeutics. 



265 



as he preferred, to direct them to increase the nutrient fats in proper quantities 
and of a suitable kind, and to administer other articles as medicine. 
The following were the author's conclusions : — 
That neither cod oil nor fat of any kind removes phthisis. 
That the cases of arrest of the disease are very few. 

That commonly the disease progresses, and is as fatal now as it was before 
the oil came into general use. 

That in about half of the cases the rate of progress is retarded. 

That the patient may be both stronger and stouter, and yet the disease 
quietly progress. 

That when the oil disagrees, it is chiefly from its influence upon the digest- 
ive organs. 

That when it agrees, it is generally by improving nutrition ; but that in 
many cases it is believed by the patient to have a local influence. 

That this local influence is most important in the pharynx and other parts 
of the mucous tract. 

That it acts almost entirely as a fat, and supplies a defect in the system. 

That it has no advantage over fats used in food, and may, like some of them, 
be taken and rejected. 

That there is a large class in whom it is not beneficial, and it should be used 
with discrimination. 

That it is our duty and our interest to dissociate food and physic. 

Lastly, that it leaves the essence of the disease untouched ; but that the 
great good which it often does temporarily, proves the importance of fat in the 
animal economy. 

He showed how much more frequently there is appetite for fat in bronchitis 
than in phthisis and mere debility, and particularly in liver diseases ; but he 
deferred the discussion of the question, and of the use of fats in general, to an- 
other occasion. He urged upon the profession the impropriety of poor-law 
surgeons being compelled to supply the oil, when the guardians ought to give 
fat in food ; and of the medical officers of hospitals and dispensaries taxing the 
overburdened funds to supply so expensive a food. 

Dr. Payne Cotton remarked that the opinions of the author respecting the 
virtues of cod-liver oil were not those entertained by the other physicians of 
the Hospital for Consumption. He himself was an advocate for its employment 
in all cases. He did not pretend to explain why it did good, but that it was of 
benefit was sufficiently evident by its effects. Under its use a great number of 
patients improved, and though it failed in some instances, it did not do so so 
frequently as Dr. Smith stated. He could only say he had undiminished con- 
fidence in its effects. He had tried other oils with a view to determine whether 
they could be substituted for it ; but they were all inferior to it. Amongst 
those he had thus tested were train oil, neat's-foot, almond, olive, and cocoa- 
nut oil. That which most nearly resembled the cod-liver oil was the neat's- 
foot. When cod-liver oil was given in the earlier stages of phthisis, in many 
cases it arrested and retarded the disease, and prolonged the life of the patient. 

Dr. Cotton had employed glycerine, but it did not act beneficially. 

Dr. Semple considered, from the experience he had had of the use of cod- 
liver oil, that it was of signal benefit in cases of phthisis. In many cases 
it prolonged life, and added to the comfort of the patient : in some instances, 
when given in the early stages of the disease, it arrested the complaint and 
prolonged life to its average duration. He had witnessed remarkable good 
effects from its administration to children affected with various strumous dis- 
eases. — Lancet, Nov. 7, 1857. 

27. Injections of the Bronchi in Pulmonary Diseases. — Dr. J. H. Bennett, 
Prof, of Clin. Med. in Univ. of Edinb., in a short paper in the Edinburgh Medi- 
cal Journal (Nov. 1857) makes the following statement: — 

" I have introduced the catheter publicly in the clinical wards of the Royal 
Infirmary, in seven patients. Of these five were affected with phthisis in vari- 
ous stages — one had chronic laryngitis with bronchitis, and one chronic bron- 
chitis, with severe paroxysms of asthma. In several other cases in which I 



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[Jan. 



attempted to pass the tube, it was found to be impossible — in some because the 
epiglottis could not be fairly exposed, and in others on account of the irrita- 
bility of the fauces and too ready irritation of cough from pressure of the 
spatula. 

" My experience of this treatment is as yet too limited to permit my saying 
anything of its permanent effects. In the case of bronchitis with asthma — a 
female, aged 24 — I have now injected the lungs eleven times, at first throwing 
in gij of a solution of nitrate of silver, of the strength of £ss of the distilled 
salt to of crystallized water, and latterly I have thrown in ^ss of a solution 
of the strength of to § j. She declares that no remedy has had such power- 
ful effect in lessening the cough, diminishing the expectoration, or delaying the 
asthmatic paroxysms. She breathes and blows through the tube, when inserted 
four inches below the larynx, and I have been surprised at the circumstance of 
the injections not being followed by the slightest irritation whatever, but rather 
by a pleasant feeling of warmth in the chest (some have experienced a sensa- 
tion of coolness), followed by ease to the cough, and a check for a time to all 
expectoration."* 

28. Treatment of Phthisical Vomiting by Local Anaesthesia. — Mr. Atcherley, 
disappointed in the effect of the orthodox remedies — as hydrocyanic acid, opium, 
bismuth, gallic acid, creasote, nitrate of silver, counter irritation, &c. &c. — for 
this condition, states (Liverpool Medico- Chirurgical Journal, July, 1857) that he 
was induced to try Dr. Arnott's method of producing local anaesthesia in two 
cases with decided success. He directed " pounded ice and common salt to be 
mixed together in the proportions used to produce anaesthesia. This poultice 
was placed in a thin muslin bag and put upon the epigastrium, and retained 
there until the skin became white and insensible; it was then removed, and 
its place supplied by lint, dipped in cold water, to prevent too sudden a reac- 
tion. As I had always witnessed great benefit from the internal administra- 
tion of chloroform in previous cases of a similar nature, I directed ten minims 
to be dissolved in two teaspoonfuls of brandy, with a sufficient quantity of iced 
water to make a draught, to be taken whenever the feeling of nausea came on. 
I gradually increase the quantity of chloroform if the smaller doses are insuffi- 
cient ; but I have seldom had occasion to exceed sixteen or eighteen minims. 
In this case it had not such an extended trial as its valuable sedative powers 
entitle it to. I have generally found it to allay the sickness for a time, even 
in the most urgent cases ; and when given in the remission of the paroxysms, 
it relieves the feeling of exhaustion and overwhelming depression consequent 
on the long-continued retching, more speedily than any other restorative. Still, 
in this patient, no permanent suspension of the vomiting took place until after 
the application of the ice poultice. No food of any kind was given till a clear 
truce of four or five days had been established, the strength being maintained 
by enemata of beef tea, jelly, and wine. 

"The effect of this treatment was most remarkable : the stomach, which had 
rejected everything in the shape of food for the space of ten days, accompanied 
with violent retching, sometimes of two hours continuance, became suddenly 
tranquillized. The vomiting ceased for a whole day and night immediately after 
the first application of the ice poultice, although it returned to some extent on 
the following morning, when the same means were employed with the same 
beneficial results. The patient has since had no return of sickness, is now en- 
joying a good animal diet, with beer or wine, as inclination dictates, and has 
been able to resume the use of cod-liver oil." 

29. Chloroform in Intermittent Fever. — M. Delioux, a professor in the French 
Naval Medical School, has long been engaged in searching for succedanea for 
quinine. Having observed that when he administered chloroform to phthisi- 
cal patients, that it not only relieved the pain in the chest and cough, but also 
moderated the fever and nocturnal sweats, he conceived it might possess febri- 
fuge powers also ; and the result of numerous trials is the ample verification 
of his supposition. He forms a syrup, by adding 5 parts of chloroform to 100 
of simple syrup, of which he gives from £j to giij in a mixture, at the same 



1858.] 



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267 



intervals afc which quinine would be given. — Med. Times and Gaz., Nov. 21, 
1857, from Union Med., No. 129. 

30. Belladonna in Incontinence of Urine. — A number of cases have within the 
last few years been reported, showing the beneficial effects of belladonna in in- 
continence of urine ; but the following, reported in the British Med. Journ. 
(Sept. 5, 1857), is the most remarkable we have met with. 

Elizabeth S., aged 4 years 9 months, was admitted under the care of Mr. 
Pollock in November, 1856, on account of incontinence of urine. It appeared 
that she had never been able to retain water since the time of her birth. The 
urine continually dribbled over her clothes, both by night and day, and she 
was, besides, teased with constant desire to pass it. On examination, nothing 
unnatural was discovered in the urine, except that it was extremely limpid. 
It was slightly acid, and free from albumen or any other morbid product. 

She was ordered purgative medicine (Pulv. scammon cum cal. gr. iv alt. 
noct.), and saline medicine, with bicarbonate of potash. This treatment was 
continued during the month of December without benefit. On December 30th 
steel was tried (tinct. ferri sesquichlor. ttjvi ter die), with blister on the loins; 
but after a full trial of this treatment for six weeks, it was given up, as no good 
was effected. On February 10th, she was ordered extract of belladonna one- 
twenty-fourth of a grain twice a day ; and this was increased on March 3d to 
one-sixteenth of a grain three times a day. She now began to improve slightly, 
so as to pass a few hours during the day without making water. On March 
17th, the quantity of the belladonna was increased to one-twelfth of a grain 
three times a day. She persevered in this treatment to May 26th, by which 
time she had so far improved as to pass three or four nights consecutively 
without passing water. The belladonna treatment was now combined with 
steel, and she has ever since been steadily improving, and is now quite well, 
with the precaution of waking her late at night to make water, and then giv- 
ing her a dose of the medicine. Still, however, if she suspends the belladonna 
the irritability of the bladder again shows itself. 



SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE 

SURGERY. 

31. Embolic Apoplexy from Detachment of Fibrinous Coagula in an Aneurism 
of the Carotid. By Dr. Fr. Esmargh. — Captain C.H., from Sweden, consulted 
a medical friend of Professor Es march concerning an attack of angina tonsil- 
laris, and at the same time drew his attention to a tumour of the left side of 
his neck which had formed suddenly, three years previously, without appre- 
ciable causes, and had now attained the size of a hen's egg. It occupied the 
upper triangle of the neck, was slightly diminished by pressure, and communi- 
cated a distinct thrill to the touch. It was at once diagnosed as an aneurism 
of the common carotid. On repeating the examination a few days later, and 
exerting pressure upon the tumour for the purpose of reducing it, the patient 
suddenly fell back with symptoms of apoplexy. He was at once bled and con- 
veyed to the hospital, where he was placed under the care of Dr. Esmarch, on 
the 8th of May, 1855. 

The patient was well built and robust ; in a state of coma, from which he 
could only be roused momentarily ; the pulse was moderately full, heart nor- 
mal. The whole right side of the face was paralyzed, the right cheek was dis- 
tended in expiration ; there were spasmodic movements in the facial muscles 
of the left 6ide. The pupils reacted to the stimulus of light. The tongue, 
which was much furred, pointed to the left. Respiration was stertorous. The 
thoracic muscles and diaphragm acted well, but only the left abdominal mus- 
cles moved in respiration. Both right extremities were completely paralyzed. 



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[Jan. 



Deglutition, defecation, and micturition were normal. The tumour pulsated 
isochronously with the carotids, but presented no murmurs. 

Professor Esmarch diagnosed the detachment of fibrin from the aneurismal 
sac, and a consequent obliteration of the left cerebral carotid. Ice was applied 
to the head, sinapisms to the legs, and an enema with vinegar was administered. 
Some improvement ensued ; the paralytic symptoms diminished, and the pa- 
tient was able to converse with a countryman; a relapse, however, followed, 
and on the 11th of May profound coma ensued ; the pulse was very quick, the 
skin cool, the complexion livid, the right pupil was somewhat drawn out trans- 
versely, but both pupils continued to react to the light ; both lips were dis- 
tended by expiration ; urine was passed involuntarily. The liver increased, 
the pulse became too quick to be counted, respiration slow, and accompanied 
by screams in inspiration; and death ensued at midnight. 

The cadaveric examination was made the day after by Professor "Weber. 

The aneurism had a spindle-shaped form, and commenced about four centi- 
metres above its issue from the aorta ; the external and internal carotids 
quitted the upper end of the aneurism, preserving their normal size. The in- 
ternal jugular vein was pushed outwards, the'vagus lay between the vein and 
the aneurism and was unaltered, but the descending branch of the hypoglossus 
was adherent to the tumour, and much altered in appearance. The whole in- 
ternal surface of the carotid from its origin was in a state of atheromatous 
degeneration, and contained enormous chalky formations ; both below and 
above, a portion of the inner coat of the artery formed a projecting ridge in the 
aneurismal sac. The sac was partly lined with a smooth red membrane, partly 
with more or less firmly-attached, ragged, fibrinous coagula : much loose fibrin, 
irregularly interwoven, was also in the sac ; a firm coagulum was drawn out 
of the internal carotid, which tore off from its continuation within the carotid 
foramen. There was no coagulum in the external carotid. Within the cra- 
nium there was found considerable hyper£emia of the vessels of the pia mater, 
a moderate effusion of serum under the arachnoid ; the whole middle portion 
of the left hemisphere, including a part of the corpus callosum, was converted 
into a pulp of a grayish-yellow colour. Beneath the aqugeductus Sylvii, in the 
mesial line of the pons Varolii, was a perfectly recent extravasation of blood of 
the size of a bean ; a smaller one, a centimetre in front of the former, and in 
the vicinity several small capillary extravasations. Normal cerebral tissue 
could not be discovered in the softened portion ; it consisted of granular mat- 
ter and short fragments of broken-up fibres, with capillaries containing shri- 
velled corpuscles. In the extravasations at the pons, the blood corpuscles 
were unaltered. The cerebral carotid, the arteria fossa Sylvii, and the arteria 
ophthalmica, were completely blocked up with coagula of a dark-brown colour, 
inclosing numerous red and grayish-white plugs, which evidently were derived 
from the aneurism. Their identity was proved by the microscope. The tho- 
racic viscera presented no marked disorganization, except that the ascending 
aorta exhibited extensive atheroma ; the same was the case with most of the 
large arteries. 

Professor Esmarch, in his concluding observations, dwells upon the danger 
of much manipulation of aneurismal tumours, as being liable to give rise to 
such consequences as those above described. He particularly discusses Mr. 
Fergusson's mode of treating aneurism of the subclavia, recently brought be- 
fore the Medico-Chirurgical Society, which consists in forcing the coagula con- 
tained in the tumour into the axillary and brachial arteries. — Brit, and For. 
Med.-Cliirurg. Review, October, 1857, from Archiv.fiir Pathol. Anat. und Phy- 
siologie, Bd. xi. 

32. Case of Arterio- Venous Aneurism, which was treated by Ligature of both 
the Artery and the Vein. — Mr. Moore communicated the following case of this 
to the Royal Medical and Chirurgical Society (Nov. 10, 1857). 

A labourer, aged 60, was admitted into the Middlesex Hospital on Septem- 
ber 30, 1857, pale and much depressed by loss of blood. Thirty-six years pre- 
viously he had been bled in the left temporal artery, and he had ever since had 
a pulsating swelling in the site of the lancet puncture. In the course of years 



1858.] 



Surgery. 



269 



it enlarged to the size of his fist ; the pulsation continued, and could he stop- 
ped by pressure with his finger in the parotid space. He had no pain in the 
tumour till August last, when it enlarged still more. One month ago it burst, 
and he at once lost two quarts of blood. Hemorrhage recurred a fortnight 
ago, which greatly reduced him, and large " lumps of flesh" were removed 
from the aneurismal cavity. On his admission to the hospital, there was an 
ulcer in the left temple as large as a crown-piece ; a clot of adherent blood 
near its anterior part ; a large abscess above the ear, from which pus issued 
in a stream through the ulcer ; and extensive oedema of the left half of the 
scalp. Moreover, a cluster of enormous tortuous, soft, pulsating vessels could 
be seen and felt above, below, beneath, and in front of the ulcer. There was 
no purring tremor in the veins of the scalp ; but the left external jugular vein 
was greatly enlarged, and had a visible arterial pulsation, together with a con- 
tinuous vibratile thrill. No other vessels were enlarged. The enlarged ves- 
sels being extremely thin, it was determined not to place a ligature upon them, 
and the temporal artery was sought for at the highest point at which it was 
presumed to be healthy. By means of a vertical incision over the parotid 
space, a pulsating vessel was reached, and a ligature passed under it. Pulsa- 
tion ceased in the temporal vessels when the finger was pressed into the loop 
of the ligature, but continued after the knot was tied. Upon examination, the 
pulsation was found to continue only on the distal side of the ligature, and the 
tied vessel proved therefore to be the vein. The temporal artery, by com- 
munication with which the vein received its pulsation, was then found in a 
situation where it might have been compressed by the finger when introduced 
into the wound. Upon tying the artery, the pulsations in the temple and in 
the distal part of the vessel previously tied at once ceased. The pulsation and 
thrill of the external jugular vein disappeared, the wound contracted," the tem- 
ple shrank, the abscess closed, and the man left the hospital on the 19th of 
October, convalescent, though still weak. The author briefly reviewed the 
effects of the treatment by compression and by ligature, which had been 
adopted in cases of permanently circumscribed arterio-venous aneurism-s. 

1. A cure had been obtained by the complete closure of either the artery or 
the vein at the site of the unnatural aperture. 

2. The obliteration of one end only of either vessel had never proved suc- 
cessful, the disease continuing or gangrene of the limb ensuing if only the 
cardiac end of the artery were tied, whilst the closure of the distal orifice only 
of the vein had but moderated the symptoms of the disease. 

3. There was reason to think that the operation just related would prove 
permanently successful, since all direct access and return of blood through the 
main vessels were cut off by the ligatures; and the orifice of communication, 
being beyond both ligatures, was reduced in importance to that of a passage 
between vessels whose circulation was only collateral. — Med. Times and G<xz., 
Nov. 21, 1857. 

33. Revision of the Doctrine of Dislocation. — Prof. Roeser lays down the fol- 
lowing maxims respecting dislocation, as illustrated by dislocations of the 
femur, derived from observations, inquiries, and experiments, continued over 
many years. 

1. The essential obstacle to the reduction of a dislocation almost always con- 
sists, not in muscular contraction, but in the narrowness of the aperture in the 
capsular ligament; 2. The difficulty of reduction generally arises only from 
its not being at once possible to ascertain the direction and position of the 
luxated head in relation to the rent in the capsule. When these are found, 
the bone is either reduced of itself by muscular action, or a slight impulse, 
rotatory movement, &c, causes the head to slide in ; 3. Much depends not 
only upon the size but upon the position and direction of the rents in the 
capsule ; 4. The head of a dislocated bone is not, as a general rule, found in 
the primary position which was given to it by the force applied; but, under 
the influence of the flexion, adduction, &c, of the dislocated limb, immediately 
following, it assumes a secondary position; 5. The reduction-process must 
No. LXIX.—Jan. 1858. 18 



270 



Progress of the Medical Sciences. 



[Jan. 



have for object, first, to restore the dislocated bone to its primary position, and 
thence to effect its return ; 6. The classification of the dislocations of every 
joint must be based upon the essential anatomico-mechanical points ; and the 
symptomatic classification adopted by Malgaigne is as unscientific as it is im- 
practicable ; 7. The most common dislocation of the head of the femur is 
downwards, when it passes beneath the tendon of the obturator internus; 8. 
This dislocation is produced by violent flexion of the hip-joint, during slight 
rotation of the thigh inwards ; 9. The dislocation downwards becomes in gene- 
ral converted during extension (with rotation inwards) into dislocation back- 
wards, luxatio ischiadica ; 10. By abduction it may be converted into a luxatio 
obiuratoria; 11. For the reduction of all these cases in which the hole in the 
capsule exists below, strong flexion appears to be necessary, in order to bring 
the head of the bone into its primary position, opposite the rupture of the cap- 
sule ; 12. The dislocation on to the foramen ovale appears to be a mere variation 
of the dislocation downwards ; 13. In the luxatio obiuratoria the head of the 
bone is placed beneath and behind the obturator externus ; 14. Malgaigne's 
41 perineal luxation" is only a slight modification of the luxatio obiuratoria ; 15. 
The dislocation forwards, between the fossa ileo-pectinea and the psoas, is pro- 
duced by excessive extension with rotation outwards. A secondary displace- 
ment results from slight flexion. The reduction is brought about by extension 
and rotation inwards ; 16. Luxation behind the pectineus is to be regarded as 
a mere modification of the luxatio ileo-pectinea. It is not to be considered as a 
luxatio obiuratoria ; 17. The extremely rare luxation on the outer side of the 
anterior inferior spine must be regarded as a modification of the luxatio iliaca, 
produced by violent rotation outwards ; 18. The luxatio iliaca is the rarest of 
all the forms of dislocation, although it is commonly regarded as the most fre- 
quent. The majority of those cases that have been so termed, and a consider- 
able portion of those cases so denominated by Malgaigne, are, in fact, examples 
of luxatio ischiadica; 19. The luxatio iliaca essentially arises from rotation 
inwards, with adduction and flexion of the limb. Its reduction is based upon 
rotation outwards. — Brit, and For. Med.-Chirurg. Rev., Oct. 1857, from Archiv 
fur Physical. Heilk., 1857. 

.34. Luxation of the Os Coccygis. — Dr. Roeser observes [Froriep's Notizen, 
1857, Bd. II., No. 10) that in the few cases on record in which this bone has 
bean dislocated, the luxation has been outwards or inwards, whereas in the 
present case it was lateral. A large, corpulent women, thirty-six years of age, 
while suddenly descending from a table on which she was standing, fell in a 
riding position across the back of a low wooden chair. Severe pain in the 
coccygeal region, which was much aggravated by attempting to sit, was the 
consequence, but she managed to get about for some hours. At last it became 
so severe that she was obliged to take to her bed, where she found she could 
neither move nor turn. After she had passed the night in this way, the author 
saw her, and found her with so changed a countenance, and such an immova- 
bility and partial stiffness of the body, as to give very much the appearance 
of approaching tetanus. Besides the severe pain in the coccygeal region, she 
complained of a painful, tense, dragging sensation, extending from below 
upwards towards the nape, stretching along the arms to the fingers, which 
were numbed. The slightest voluntary movement of the body, or of the head, 
to one side or the other, and still less sitting up in bed, could not be borne. 
The head was confused, and the intellect somewhat clouded. There was no 
unnatural sensation in the lower extremities, and the urine and feces were 
passed naturally. Upon examination, a small swelling was felt on the left side 
of the fissure of the buttocks, which proved to be the coccyx torn away from 
the sacrum, and carried towards the descending ramus of the left ischium. 
The end of the sacrum whence it had been displaced could be plainly felt. 
When a finger was introduced into the rectum, the exact nature of the dis- 
placement was still better ascertained; and when firm pressure was made 
downwards and to the right against the displaced bone, it suddenly resumed 
its normal position. The patient declared she immediately felt quite another 
being, the confusion of the head and painful sensation along the spine and 



1858.] 



Surgery. 



271 



arms disappearing. At the end of the fifth day, no inconvenience beyond a 
slight burning pain near the sacrum remained. — Brit, and For. Med.-Chirurg. 
Rev., Oct. 1857. 

35. On the Prevention of the Ill-consequences of Operations. — Prof. Deroubaix, 
Surgeon to the St. Jean, Brussels, terminates a series of papers upon this sub- 
ject with the following summary: — 

1. If it is the duty of a surgeon to seek, by the improvement of his operative 
procedures, to obviate the immediate accidents of operations, the endeavour to 
discover the means of prevention of the secondary accidents, which are far 
more dangerous, is still more imperiously demanded at his hands. 2. Could 
the great surgical operations be rendered less dangerous in themselves, the 
intervention of surgery would be much more clearly and more frequently indi- 
cated in cases where the practitioner now often is obliged to remain a passive 
spectator of disorders which infallibly prove fatal. 3. The danger of great 
operations is not due to the size of the surfaces concerned, but to the number 
and volume of the veins divided. 4. When the division of veins proves mis- 
chievous, it does so by giving rise, through a mechanism the nature of which 
it is not always easy to appreciate, to the production of purulent infection, one 
of the most fearful consequences of traumatic lesions. The great danger and 
extreme frequency of this complication justify the efforts made for its preven- 
tion or removal. 5. There are two directions, both perhaps equally good, by 
following which we may succeed in rendering pyaemia of much less frequent 
occurrence. The first of these consists in improving and rendering less un- 
certain the process of healing by the first intention ; and the second in so 
modifying the divided surfaces as to convert them into a lesion of continuity of 
far less dangerous character. 6. Metallic caustics, at least in the immense 
majority of cases, do not give rise to purulent infection ; but they are not ap- 
plicable to certain operations — as, e. g., amputations. 7. It is rational, then, 
when seeking for substitutive or modificatory means for the prevention of 
pyemia, to resort to such as most resemble caustics in their mode of action, 
and yet are exempt from the disadvantages of these therapeutical agents. 8. 
The tincture of iodine would seem to possess properties enabling it to fulfil 
these indications, seeing the deep-seated modification it impresses on the tissues, 
and the plastic effects it gives rise to. It does not act upon the ligatures, and 
therefore does not give rise to the danger of secondary hemorrhage. When it 
is applied to bleeding surfaces after an operation, it induces a general hypos- 
thenic effect of short duration, and a local hyposthenic effect, which imparts 
peculiar characteristics to the granulations and cicatrization. 9. The most 
remarkable results of this hyposthenization are, the much less indolence of the 
wound, the slight amount of suppuration, the notable diminution of the general 
reaction, and the maintenance of a condition approaching that of health. These 
phenomena offer no impediment to rapid cicatrization. 10. The discharge from 
the surface of the wound is considerably diminished as a consequence of the 
application of the tincture ; but this does not prevent arterial hemorrhage, or 
the loss of blood from the large veins. 11. The putridity of the wound becomes 
evidently diminished ; and when the tincture is applied to the divided extremi- 
ties of the veins, these become corrugated and narrowed, and then agglutinated. 
If phlebitis arises, it is obliterative and adhesive, not suppurating. 12. The 
application of the tincture to the sawji surface of the bones does not lead to 
necrosis. 13. The tincture imparts no preservative power against pyaemia 
when an open -venous orifice, through which pus may be easily, so to say, me- 
chanically introduced exists at any point of the surface. 14. In ordinary cases, 
even the tincture is no certain preventive of purulent infection. When, after 
it has been applied, we find the vicinity of the wound remaining very painful, 
we should suspect a commencement of phlebitis, and the course of the pain 
should be carefully inquired into. 15. It should be remarked that, as the 
general hyposthenization which results from the application of the tincture 
exhibits itself in symptoms, comparable to a certain point to those produced 
by chloroform, prudence is required in the simultaneous or successive employ- 
ment of the two substances. Perhaps this is the principal defect in the iodine. 



272 



Progress of the Medical Sciences. 



[Jan. 



16. The injection of the tincture into the veins is immediately fatal. It induces 
an entirely peculiar coagulation of the blood, incapable of being confounded 
•with any other pathological or spontaneous coagulation. 17. Nevertheless, 
this medicinal substance cannot, when applied to a bleeding surface, be carried 
in substance into the torrent of the circulation, unless, indeed, venous orifices 
be maintained open by adhesions. It is absorbed in the state of an alkaline 
iodide, and may be found in such a state of combination in the blood and urine. 
The amount ordinarily absorbed exerts no ill effect upon the economy. — Brit, 
and For. Med.-Chirurg. Rev., Oct. 1857, from Presse Med. Beige, 1857, Nos. 17-24. 

36. Amputation at the Knee-joint, leaving the Articular Surface entire. — Mr. 
Lane communicated to the "Western Medical and Surgical Society (Oct. 23, 
1857) some remarks on this operation. He advocated its adoption in all cases 
where the disease was confined to below the joint in preference to the more 
common practice of removing the femur at its lower third. Mr. Lane stated 
that he had, for the first time in England, performed this operation about five 
weeks ago, and exhibited the subject to the members. It had been performed 
in Glasgow in 1847 once, and in the Crimea seven times, in three of which the 
patient recovered. It had been performed eighteen times in America, with 
five deaths ; and twenty-eight times on the Continent, with twelve deaths ; 
giving a percentage of 31 deaths, whilst that from amputation of the thigh 
was about 43 J: hence the recommendation of the present plan. He described 
the operation, recommending a large anterior flap to be made in front of the 
joint down to the insertion of the ligamentum patella, which was to be turned 
up and the knife carried through the joint, and a small posterior flap to be 
then made, so that in healing it w r oulddraw the anterior flap over the articular 
surface, the cicatrix being then behind the joint. The advantages of this plan 
were apparent in the decreased mortality, and in the after usefulness which 
would arise from the stump being capable of bearing the pressure of the body 
better than does the divided femur. Mr. Syme and Mr. Fergusson had recom- 
mended a similar operation, but it differed in the removal of the articular sur- 
face, and in the recommendation to make a large posterior flap, which was 
objectionable on account of the tissues of the calf being unaccustomed to pres- 
sure and unfit for the proposed work. — Lancet, Nov. 7, 1857. 

37. Results of the Operation of Tracheotomy performed for Group at the Chil- 
dren's Hospital, Paris, during the Tear 1856. — The Bulletin de Therapeutique 
(May 30, 1857) contains an extremely instructive table respecting tracheotomy 
in croup, taken from the thesis of M. Andre, late house-physician (interne) of 
the Children's Hospital : — 



Age. 


No. OF 
Patients. 


Deaths. 


Kecoveries. 


Boys. 


Girls. 


Boys. 


Girls. 


From 15 months to 2 years . 


G 


2 


4 






" 2 years to 3 years 


9 


4 


3 


2 




"3 " 4 " . 


13 


5 


4 


4 




" 4 " 5 " 


11 


6 


3 


1 


i 


5 « Q U 


6 


3 


1 


1 


i 


" 6 " 6J " 


o 
o 


1 


1 




l 




2 




1 




l 


" 8 " 


2 




1 


1 




" 9 « 


1 






1 




" n- v< 


1 








i 



From this table it appears that many successful cases of tracheotomy have 
been observed, as nearly one-third of the patients recovered. The most notable 
success has been obtained with children from nine to nine years and a half 
old, and then with those children who were from five to six years old. The 
least satisfactory results were observed from fifteen months to two years, for 



1858.1 



Surgery. 



273 



here we have six operations and six deaths. All the children under two years 
are to be found in the column of deaths ; and all those who died, except two, 
were just a little more than two years old. M. Andre thinks that these facts 
may